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0400 (MISC)I PERMIT APPLICATION - City of La Duinta Department of Building and Safety 7 '''X` ' 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' COMPENSATION 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) o, less. I certify thEt.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 in any manner so a; to become subject to the Workers' Compensation laws of and effect. California. 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 violatiorrof Section 7031.5 by any. applicant for a permit, subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): . A(lf as owner.of the property, or my employees with wages.as their sole compensation, will do the work, and the U str➢cture is not.intended or offered focsale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply io 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 forsalerlf, however, the building or i mprovemnt 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.). O I, as.owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code: The Contractors 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.). O I am exempt under.Sec. - ..8.,8 P.C. (Attached Certificate). Date V. `•'�� �� Owner ,. <ic',C. .��. -, �� `.;•.�., WO KERS' COMPENSATION DECLARATION: I h reby affirm that 1 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 O Certified copy is hereby•furnished.. - O Certified copy is filed with'the City Building Inspection Department or City Department. Date Applicant - APPLICANT NAME (L. F; MI) / '01%, Z/ Z M, f�[ A°s=i- 9Z/5 CITY/COMMUNITWSTATE/ZIP - JOB SITE ADDRESS/SPACE - CITY/COMMUNITY/STATE/ZIP w BOK PAG PRC C h TWN RNG SE S TRACT I j LOT � t : Moo Set > TRACT NAME OWNER NAME (L. F. MI) - CONT% CTOR-FIRM NAME j� 1 ADDRESS CITY/COMMUNITY/STATE/ZIP ,PHONE • 0 ' LICNC II ARC/ENG FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE • LICNC II USE OF PERMIT. & •�arJ�i c9 ...5 d o J^ /` i�i9� e BL ZONFSB SSB SSB RSB OFC ZONE ORD k LOT SZ END SIDE, Date Applicant NOTICE TO APPLICANT: If, after making this Certificate if Exemption, you should become.subjectto the Workers' .. Compensation provisions of the Labor Code, you must brthwith comply with such -provisions or this permit shall be deemed revoked:` DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATI )N: 01 hereby certify` that no excavatioritive (5) or more feellin depth into Which a persbn is required to descend, will be ' made in connection with work authorized by this pe(mit and that no building structure, scaffolding, falsework, or demolition of dismantling'thereoL:will be more than thirty-six (36) feet high. (Chap -12, Grp, 2, Art 2, Sec341, Title B, C.A:C.) .. , O As owner -builder, I will not employ anyone to do vork 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. s O.Division of Industrial Safety Permit No. Date Applicant CONSTRUCTION LENDING AGENCY: I hereby affirm that Mere is a construction lending agency for the performance of the work.tor whichthis permit is issued (Sec. 3097, ',iv. C.). ` Lender's Name Lender's Address I certify that.l have read this application and state that tare above information is correct. I agree.to comply -with all - city and county ordinances and state laws relating to bulding construction, and hereby authorize representatives z of this county to enter upon the above-mentioned property for inspection purposes. ' W Signature of Applicant or Agent Date CERTIFICATE OF. COMPLIANCE AND AUTHORIZATION OF :NTRY: 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 Cit, of La Duinta Department of Building and Safety to enter'' upon the property for which f have applied for this permit for the.purpose of making inspections. Signature of Applicant or Agent Print Applicant/Agent Name Date APPL/PRMT MOO , - D T� 7 g h c " � t : el V� Pi 0 ' T� FEE VALUATION e� CA^ BLDG. DEPT. _ w 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. ❑ NPON ADDITIONAL INFORMATION I (, / ( v / j'� SEWAGE SYSTEM SIZE &. LOCATION 11 Exterior Lath 12 Internal Lath 12A Drywall •t 13 Finish Grade INSULATION Thick R 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 P/L P/I STREET NAME 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring 29A Grounding Wire 298 Bonding 30 Fixtures 31 Service 32 Final PUMPING INC. . Box 2448 CALIFORNIA 92235-2448 Qan_7daa JOB INVOICE i7-60)321-7448 DESCRIPTION OF MATERIAL USED PRICE CUSTOMER'S ORDER NO. DATE ORDERED G Gallons ORDER TAKEN BY DATE PROMISED ❑ A.M. F�_T� - ❑ P.M. T� ► s'T A n/ s -7- Dumping Fee per 1000 gal. PHONE ADDRESS MC-)'TNIC Out of Area Fee !/� Ov, CITY T / - HELPER JOB NAME AND LOCATION - C? _ Ave, V1, 1 1. DESCRIPTION OF WORK t ..eU LAIKA .. Size System: f � QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT Gallons �) Pumping Fee per 1000 gal. j Dumping Fee per 1000 gal. Out of Area Fee i Locating / Opening Fee (per hour) t ' Size System: f � A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS. 18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. 'S LABOR AMOUNT MECHANICS Qa TOTAL MATERIALS HELPERS Q acknowledge the satisfactory TOTAL LABOR ion of the above described work: DATE COMPLETED r TOTAL LABOR TAX TOTAL `s= /C'31/N-S-re IIA-* i o A,1 .OV 1 0006 Rol i7t' ax p oe� /,V- A-.4 < .L 3 • � 79� 9 y� �a0� li�,eT + i �e�oe.^OA OP ArrrA-V �� /.♦ Y' � ..