0217 (PLBG)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
This permit becomes void i1 work not commenced within 180 days from date of issuance, OR, if work has been suspended or abandoned for : period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with.Section 7000) of Division Sof the Business and Professions Code, and my license is in full force
and effect.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct•, alter, improve, demolish• or repair any structure• prior to its issuance. also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
❑ I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044• Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon• and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
❑ 1 am exempt under Sec. k ?B. 8 P.C. (Attached Certificate).
/Date J- t Owne"IA' A t�/k. •.epi • X4—
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy
Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City
Date Applicant
Department.
APPLICANpTNAME (L. F. MI)
tj,_ f Ea Ems. f A i�i 4, f / /�f l"C / ; P✓ t a �:•..
l/
ADDRESS d/J� ^, �y }j t
!: 7 P•I l/C , f / J f�Y
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE /� J�
%f ilm .' A .- /'r p,) ✓ �»
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
C
TWIN
FIND
SE
S
TRACT
LOT
MOD
Se
TRACT NAME
OWNER NAME' F..MI)/1
'-vim„ 1:r /0 4,. . /J, �, . t'S f✓ .
CONTRACTOR -FIRM NAME
ADDRESS I
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
USE OF PERMIT
BL
I
I ZON
FSB
SSB
SSB
RS8
OFC
ZONE ORD N
LOT SZ
TOTAL
FEE
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify tha in the performance of the work for which this permit is
issued. I shall not employ any person in any manner so a=_ to become subject to the Workers' Compensation laws o1
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must fc rthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 hereby certify that no excavation five (5) or more feet I depth into which a person is required to descend. will be
made in connection with work authorized by this permit, and that no building structure, scaffolding�falsework, or
demolition or dismantling thereof, will be more than thirte-six (36) feet high. (Chap 3.2. Grp 2. Art 2, Sec341. Title B,
C.A.C.)
❑ As owner -builder, I will not employ anyone to do vnrk which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
O Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that Were is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. Q.
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information -is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned propety for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF E (ITRY: I certify I have read this application and state that
the information given is correct. I agree to comply with a 1 state laws and county ordinances relating to buidling
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which l have applied for this perrrit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT
NZ
tDATE
0217
�V,'rJ e1A +e�,",
.,I
K f 7'
'iP •Cis
f
TOTAL
FEE
VALUATION
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept.
l
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
Slab Grade
35 Furnace Compart.
3
Steel
36 Inlets & Outlets
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof Deck
39 Appl. Clearance
7
Framing
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage Fire Wall
42 Commercial Hood
10
Fireplace P.L.
❑
43 Final
10A
fireplace T.O.
❑
OP'N ADDITIONAL INFORMATION
NO.
/ `2
�v /�/Y�—�� faj j
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
p/L P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME