0876 (BLCK)PERMIT APPLICATION 3 t 0 of L
City of La Duinta
Department of Building and Safety
- , - • ' This permit becomes void if work not commenced within 180 days from date of issuance•.OR, -if work has-been suspended or abandoned for a period.of 180 days.: ^
' -
CERTIFICATE OF EXEMPTION FROM WORKERS" C3MPENSATION INSURANCE: This section need not be completed if
' 'LICENSED CONTRACTORS DECLARATION: I hereby. affirm, that'I am'licensed.under'provisions,of Chapter,9. " :
the permit is,for one hundred.($100) or less. I certify that in the performance of the work for which this permit is ,
(commencing with Section 7000) of Division Sof the,Business and Professions Code, and my license is in full force .
issued, I shall not employany person in any marnerso as to become subject to the Workers' Compensation Laws of
and elfect.
California.
License Class - Lic. Number
Date Appliont•
Date " Contractor •NOTICE
TO APPLICANT,, alter makingahis Cedificate 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, yo./.must forthwith comply with such provisions or this 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 CER IFICATION:. .. .
,..5uch permitto fileasigned statement that he is licensed. pursu@nt to the provisions of the Contra.clor-'s License Law.
01 hereby certify that no excavation five (5) or nore feet in'depth into which a person is required to descend, 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 by thi. permit,and that 'no building structure, scaffolding, falsework; or
therefrom and the basis for the alleged exemption: Any.violation of.Section 7031.5 by any applicant for a permit
demolition or dism intlin§thereof; will be more Nan thirty-six (36) feet high. (Chap 3.2,.Grp 2 Art 2: Sec 341, Title 8F
subjects the applicant to a civil penalty of not more than -five hundred dollars ($500.):
C A.Ci)
O I: as owner of the property, or -my employees with wages as their sole compensation, will do the work, and the .
O.As owner,builder: I will not employ anyone to do work -which would require a permit from the Division of r
..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 divisions
Law does not apply to an owner property who builds; or improves thereon, and who 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 of Industrial Safety Permit No. :
building orimpro_vemntissold within one year ofcompletion, the owner -builder will have the burden of proving that .-
- -. Date Appliont•
he did,not build or.improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: .I herebyaffi-mthat there is a construction lending agency for the performance. -
O I, as owner.of the property: am•exculsively contracting with licensed contractors to construct the project (Sec.' %,
of the work for which this permit is, issued (Sew. 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 forsuch projects with a contractor(s) licensed pursuant to the
- - -
Contractor's License Law.).
Lender's Address
' O 1 a exempt under. Sec. B. 8 P.C. (Attached Certificate).
I certify.that I have read this application and state that the above information is correct. I agree to comply with all
Date owner - x '1' * = vi+� _ `
city and.county,ordinances and state laws relat ng to building construction, and hereby authorize representatives
•' LOT SZEND
of this county to enter upondhe above-mentioDed property for inspection purposes.
•• WORKERS' 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 Agem Date
. Policy No. Company
CERTIFICATE OF COMPLIANCE ANDAUTHORI7AIONOF.ENTRY:JcertifyIhavereadthisapplicationandstatethat
❑ Certified copy is hereby furnished.
the information given is.correct. I agree to cor olywith all state laws and county ordinances relating to buidling
O Certified copy is, filed with the City'Building Inspection Department or City Department.,
construction, and authorizea 'representative o•.theCity of La Ouinta Department of Building -and Safety to enter
upon the property for which I have applied for -this permit for. the purpose of making inspections..
Date Applicant
_`J[, , . _.
Signature of Applicant or Agery Date
Print Applicant/Agent Name
APPLICANT NAME -(L. F. MI) -
tuSriN
ADDRESS -
5-3-670 A/// .q
CITY/COMMUNITY/STATE/ZIP ..
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JOB SITE ADDRESSISPACE
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CITY/COMMUNITY/STATE/ZIP
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FEE
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME .... -• -
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. .
PHONE •
.LICNC M
- -
ARC/ENG FIRM NAME
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP -
PHONE •
..LICNC
USE OF PERMIT
BL,-
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SSB
SSB
RSB
OFC. .
' ZONE ORD •
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•' LOT SZEND
SIDE'
APPL/PRMT 5� 79AX
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93 1t1LC,4V_ . cT _ 42 f 0 A// 6:W
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f, TOTAL
FEE
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BLDG. DEPT . VALUATION
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.
❑
NPN
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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)
12.0 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/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final