0683 (CCOM)•'LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Divi
and effect. .;
License Class Lic. Number
Dale 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 ajleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):••
❑ I. as owner of the property. or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (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 does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
r,. building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
f„i he did not build or improve for the purpose of sale.). ro
�. ❑ I, 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.).
kO Iam exempt unAei Sec. i - •B?8 P.C`,(Attached Certificate). ,
Da
te^ — / t / Owner J/
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a '
certificate of Workers' Compensation Insurance , oha certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
❑ Certified copy is -hereby furnished.
❑ Certified copy is filed with:lhe City Building Inspection Department or City Department.
Date Applicant
PERMIT APPLICATION
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.
- • I CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
ON: I hereby affirm that I am 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
sion 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'Compensation Laws of
California.
APPLICANT. NAME (L, F,, MI)
P E-5 E'
ADDRESS_ -- '
CITY/COMMUNITY/STATE/ZIP '
C /4 c�2U/NT1q
JOB SITE ADDRESS(SPACE '
CITY/COMMUNITY/STATE/ZIP
BOK
PAG
PRC
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TWN-.
RNG
SE
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TRACT
LOT
TOTAL
FEE
MOO
SB
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR-FIRM•NAME - - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
-
LICNC
USE OF PERMIT '
BL
I
I ZONFS8
SSB
SSB
RSB
OFC'
ZONE ORD
LOT SZ
1.END
SIDE '
Date Applicant
'.NOTICE.TO.APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed'revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 1 hereby certify that no excavation five 15) or more feet in depth into which a person is required to descend, will be
made in connection with work authorised by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2, Sec 341, Title 8.
O As owner -builder, I will not employ anyone to do work which would require a permit from the Division dl
Industrial Safety, as noted above, unless -such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
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.). z
Lender'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 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 to 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 •, Jr 1[JI /C./ /./E%
__2 J Q
'54
o.
TOTAL
FEE
r VALUATION =�210j - (a
BLOG.DEPT.
.k
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION —T—DATE INSPECTOR—'
BUILDING. APPROVALS
MECHANICAL APPROVALS
1
Set Back
-33
Ventilation System -
2
Ftgs & Firms
34
Plenums & Ducts
2A
Slab Grade
35
F6rnace,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.
0
43
Final
10A
Fireplace T.O.
ED
OWN ADDITIONAL
NAL INFORMATION
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) L
STREET.NAME.
26 Power Pole
27 Conduit
28 Service Entrance
29 -Wiring
29A Grounding Wire
29B. Bonding
30 Fixtures
31 Service
32. Final