0841 (SOTB)r ,
PERMIT APPLICATION
' - City of La Duinta `
Department of Building and Safety .
. - I This permit becomes .void if work not commenced within 180 days from date of issuance, OR, if work has been suspended or ab:_ndohed for a period of 180 days.
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CERTIFICATE OF EXEMPTION FROM WORKEFS'•COMPENSATION INSURANCE*. This section need not be completed if -
' 'LICENSED CONTRACTORS DECLARATION; P hereby affirm that I am licensed under' provisions of -Chapter 9 '
'the permit is for one hundred (5100) 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 inanymahnerso asto become subject to the Workers' Compensation Laws of
and eflect.
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' '
' OWNER -BUILDER DECLARATION:' ' I hereby'affirm that I.am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you must forthwith comply with such provisions orthis permit shall '
-" ' '
following reason (Sec. 7031.5. Business and Professions Code: -Any city or county which- requires a permit to
be. deemed revoked.
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 heis licensed pursuant to the provisions of the Contra * clot's License Law ;' ;
'01 hereby certify that no excavation five (Soimore feetin'depthinto which aperson isrequired todescend, will be
.(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt, ..
' made.in'connection with work authorized tr this permit, and'that no building structure; scaffolding; falsework; or '
-' therefrom and the.basis for the alleged exemption. Any violation;ot Section,7031.5 by any applicant for. a per .
If or dismantling tfieieof, will be rr3re than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8, -
subjects the applicant to a civil penalty of not more than five hundred dollars•(S500.): '
C.A.C.) "
10 Las owner of the property, or my employees with wages.as their sole compensation, will do the work; and the. •
0' As owner -builder, I will not empjoy amrone to do worlr which' would require a permit from the Division of
•structure is not intended.oi offered for sale (Sec. 7044,.Business and Professions Code: The Contractors License
Industrial'Safely;'as noted above, unless _uch 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 who does such work himself or ..
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the'.'
O Division of Industrial Safety Permit No ,
building or improvemni is sold within one year of completion: the owner -builder will have the burden of proving that, .. ..
Date RpplicanP '
he did not build or improve for the purpose of sale.)..
CONSTRUCTION LENDING AGENCY: I hereb.x affirm that there is a construction lending agency for the performance' ' ✓
.0 I, as'owner of the property, am exculsivefy contracting with licensed contractors to construct the project (Sec: •: '
of the work for which this permit is issue.i (Sec. 3097, Civ. C.). ':• - " " --
7044, Business and Professions Code: The Contractor's License Law does not apply to an.owner of property who. ... '
Lender's Name '
-'builds-or improves thereon, and•who contracts for.such projects with a contractor(s) licensed pursuant to.the -
FSB
Contractor's License Law.).
-Lender's Address
<: "❑ ram:exem, f under Sec;' • ` " B.4 P.C. (Attached Certificate),
I certify that I hamread this application aid state that the above information is correct; I agree to comply with all '
/ Owne :.�.-o:� ( a .jam 2 :
city and county ordinances and state laws elating to building construction; and hereby authorize representatives'
_
of. this county to enter upon the above-mentioned property for inspdction purposes:
WORK RS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora '
'certificate of Workers' Compensation Insurance , or. a certified *Copy thereof (Sec: 3800. Lab.'C.):
Signature of Applicant or kgent ' Date
Policy No.. Company „
CERTIFICATE OF COMPLIANCE AND AUTHL9IZATION OF ENTRY: I certify I have read Misapplication and state that'.
' 0 Certified copy is hereby furnished. <:- '.
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling'
O'Certified copy is filed witfi'the.City Buil..ing Inspection Department or City Department.
construction, and authorize a'representatve of the City of La Ouinta Department of Building and Safety to enter -
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upon the property.for which I have applied for this permit for the purpose of making inspections:
Date Applicant
'
Signature of Applicant or Agent Date
.APPLICAN NAME (L.;F, MI),. • ' -
rf� 7Jf��/1�
ADDRESS- '
•.3-,53..3
CITY/COMMUNITY/STATE/ZIP -
.G' /1"N v /.tN A
JOB SITE AOD EESS/SPACE '
CITY/COMMUNITY/STATE/ZIP
BOK ,.
PAG
PRC
C
-
TWN
'RNG
SE.
S
TRACT
•LOT
' 5 ' TOTAL
FEE
MOD
- SB
...-7—
TRACT NAME
OWNER NAME
A(LGF. MI(
CONTRACTOR -FIRM NAME - ..
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
• PHONE 0
LICNC i
-ARC/ENG FIRM NAME - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N -
LICNC N
USE OF PERMIT - -
BL
ZON
FSB
Sss
SSB
RSB
OFC
•. ZONE ORD•. '.:...-
..,
LOT SZ '.
END
SIDE
Print Applicant/Agent Name
i; VALUATION
.. BLDG. DEPT. ._ ; A
' 5 ' TOTAL
FEE
i; VALUATION
.. BLDG. DEPT. ._ ; A
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.
❑
NON
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R"
Value
7A Walls (Batts)
12B Ceiling (Batts)
12CT 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
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final