0548 (BLCK)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety.
!tea-_ _ r?•b. • . This permit becomes void it work not commenced within 180 days from date obissuance; OR, if work has been suspende or abandoned for a period of 160 Rays. -
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if '
LICENSED CONTRACTORS DECLARATION: I hereby affirm that Lam. licensed under provisions .of' Chapter 9 : '.the permit is for one hundred ($100) o, less: I certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the -Business and Professions Code, and my license is in full force issued, I shall not employ any person inany mannerso asto become subject tothe Workers'CompensationLaws of
and effect. California.
License Class Lic. Number Date Applicant .
Date Contractor. NOTICE TO APPLICANT: If,.after making this Certificate of Exemption, you should become subject to the Workers'
ti., •• •• Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
OWNER -BUILDER DECLARATION: --I hereby affirmthat I am exempt from the Contractor's License Law for the be deemed revoked.
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 DIVISION OF INDUSTRIAL SAFETY PERMIT, CERTIFICATION:
such permit to file a signed statement that heislicensed pursuant tothe provisionsofthe Contractor'sLicenseLaw Olherebycertifythat noexcavation five (5)ormore feet indepth into which apersonisrequiredtodescend, will be
.(Chapter 9 (commencing with section 7000) of Division 3.of the Business and Professions Code) or that he isexempt made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewoik, or
..therefrom•and the basis for the alleged exemption. Any,violation of Sectiom7D31.&by any applicant for a permit , demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341. Tille6,
subjec s.the applicant to a civil penalty of not more than five hundred doljars, ($500.): C.A.C.)
C
~rl"as owner of the property, or my employees with wages as their sole compensation, will do the work, and the • • ❑ As owner -builder; Il.will not employ anyone to do work4hich would require a permit from the Division of.
structure is not intended or offered for.sale (Sec: 7044; Business and Professions.Code: The Contractor's License . Industrial Safety, as noted above, unless such person has a permit -to do such.work from that division.
Law does not apply to an owner of property who builds, or improves thereon, and wwho does such work himself or . . .. . r ,
through his own employees. provided that such improvements are not intended or offered for sale: If; however, the . - O Division ot,lndustrial Safety, Permit No,
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.).
1. x-.
71
0. 1. 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.). ,r•. 1
❑ I am exempt underSec: ! 9: 8 P.C. (Attacped Certificate)::.-
Date r ...1. X "L Owner r7 .cam P' I -AA t/
WORKERS' COMPENSATION DECLARATION: I he epy 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 No. Company y
O.Certified copy is:hereby furnished.
'O Certified copy is filed with theCityBuilding Inspection Department or City Department.
Date Applicant
APPLICANT
/�NAME (L. F, MI) p
ADDRESS '`� �/.�{, j j{' (j( •`
l L� u / • rll - Y'' C/\ c4
CITY/CO -,—" /STATE/ZIP L �� z
JOBSITEEjj._A.•trDDRESS/SP(AC3E�,/`.
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
:,C -
TWN -
RNG
SE
S
TRACT
LOT
MOD
SB,
,
TRACT NAME
OWNER NAME (L. F. MI) - - -
CONTRACTOR -FARM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
,
ARC/ENG FIRM NAME ,
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
�ONt t, &, `
,.
LICNC N
USE OF PERMIT ..
BL
ZON
FSB
sse
SSB '
RSB
OFC • ',
ZONE ORD N
LOT'SZ -
• • END
SIDE
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is.issued (Sec. 3097, Civ..C.):
L'ender'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- property for inspection purposes: '
Signature of Applicant or Agent " ' �" Dafe
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the -information given is correct. I agree to comply+with all state laws and county ordinances. relating to buidling:.
construction,.and-authorize a representative of the City of:La Duinta Department of Building and Safety to enter , .
upon the property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date -
Print ApplicantlAgent Name
APPLJPRMT
r
'TOTAL
FEE
BLDG. DEPT. VALUATION
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPErTOR
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.
❑
NOADDITIONAL INFORMATION
^ eq! (,
f/G
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
R
INSULATION Thick Value
7A . Walls (Batts)
12B 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
PSL P/1
STREET NAME
26 Power Pole
27-, Conduit
28 Service Entrance
-
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final