0584 (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 fora period of 180 days.
ADDRESS — ,C--?
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it .
LICENSED 'CONTRACTORS DECLARATION: I hereby affirm that 1. am licensed under, provisions of Chapter :9
the permit'is for one hundred ($100) o, less. I certify that in the performance o1 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 as to become subject to the Workers'CompensationLaws of
and effect. /�}
California.
License Class Lic_ Number • s ! /
Date Applicant
—Date - Contractor ^? s- +� �f� �
NOTICE TO APPLICANT: It, 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 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 CERTIFICATION:. -
suchpermittofile a signed stateme ' nt that he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no excavation five (5) or more feet in depth into Which a person is required t6 descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 o1 the Business and Professions Code)or that he is exempt
made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or
therefrom and the basis for the alleged exemption Any violation of Section 7031.5 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, Sec 341, Title 8.
`nsubjects the applicant to a civil penalty of not more -than five hundred dollars (5500.): -
C.A.C.) * '•�' '
❑ I. as owner of the property, or -my employees with wages as their sole compensation, will do the work, and the,
' ❑ As'owner-builder: I will not employ anyone to do work which would require a permit from the Division' of
structure is not intended or.offered for sale (Sec. 7044. Business and Professions Code: -The Contractors 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 who does such work himself or
CITY/COMMUNITY/STATE/ZIP .. '
through his own employees, provided that such improvements are not intended or offered;for sale. If, however, the ..
0 Division ofIndustrialSafety Permit No.
building or improvemni issoldwithin one year of completion. the oTner-builder*11 havethe burden ofprovingthat
Date Applicant
he did not build or improve for the purpose of sale.). • L :
CONSTRUCTION LENDING AGENCY: I hereby affirm that 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 (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
SSB
Contractor's License Law.).
Lender's Address
O 1 am 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 - �+ - -
city and county ordinances and state laws relating to building construction, and hereby authorize representatives -
LOT SZ
of this county to enter upon the above-mentioned property for inspection purposes:
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or,a
•END '
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab: C.).,
Policy No. Company
❑ Certified copy is.hereDy furnished.
• Certified copy i0iled with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F, MI)
hA7+E ,,
ADDRESS — ,C--?
CITY/COMMUNITY/STATE/ZIP
JOB SITE AOORESS/SPACE ,
CITY/COMMUNITY/STATE/ZIP ..
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TOTAL
• - FEE
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TRACT NAME•
OWNER NAME (LI. F,
CONTRACTOR -FIRM NAME
ADDRESS ^
CITY/COMMUNITY/STATE/ZIP -
PHONE II
LICNC II
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. '
PHONE N
LICNC 0
USE OF PERMIT -
BL
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FSB
SSB
SSB
RSB
OFC
ZONE ORD $
LOT SZ
•END '
SIDE
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Signature of Applicant or Agent Date
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 4o buidling -
construction, and authorize a representative of the City 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.'
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT - ^ DATE/�
fT �a IN s7,4,4f SO -Z,0,19
.S S P4ezz:>Af_
• �ysa
TOTAL
• - FEE
VALUATION
BLDG. DEPT.
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
7 (%
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 07 77
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/l
STREET,NAME-
26 Power Pole
27 Conduit
.28 Service Entrance
29, Wiring
29A Grounding Wire
2913' Bonding
30 Fixtures
31 Service
32 Final