0852 (BLCK)PERMIT APPLICATION �' }�•O O
City of La Duinta
Department of Building and Safety
,. - This permit becomes void if work notcommenced within 180 days from date -of issuance. OR, if work has beewsuspended or;abandoned'for a'period'of 180 days.
LICENSED CONTRACTORSDECLARATION: t hereby.affirm that -I am licensed under' provisions of Chapter.9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and rny.license is in full force
and eflect.
Licegsle Class f r Nuintior
Dater ntraMor ��
OWN -BUIL ER DE "ARATION: (hereby affirm that Idm eaemptfrom the Contractor's License Law for the
following reason: (Sec:.7031 A 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 pursuantto the provisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3.of the Business and Professions Code)pr that he is exempt
therefrom and the basisJor the alleged exemption. Any violation of Section 7031.5.Dy any applicant for a permit
subjects lhe.applicantto a civil penalty of not-morethi ui five hundred dollirs
o I. as owner of the property, or my. employees.with wagwas 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 offeied.foi site. IC however. the
building or improvemnt is said 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 sate).
❑ 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.).
O 1 am exempt under Sec. 8.8 P.C. (Attached Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I 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
❑ Certified copy is hereby.fumished. -
❑ Certified copy is filed with the'City.Building Inspection Department or City. .Department.
Date Applicant
APPLICANT NAME.(L. F. MI) '
ADDRESS -� - -• ..
-CSU/
CITY/COMMUNITY/8TATE21P
JOB SITE ADOREe3/SPACC ,•
61TYA)OMML)NITY/STATE/ZIP - -
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TRACT NAME
OWNER NAME IL. F. MI) - - -
CONTRACTOR -FIRM NAME • .. . .
ADDRESS -
CITY/COMMUNITY/STATE/ZIP -
PHONE.e
LICNC e
ARC/ENO FIRM -NAME ..
ADDRESS
CtTY/COMMUNITY/STATE/ZIP
PHONE a
LICNC e
USE OF -PERMIT -
BL
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ZONE ORD 1LOT
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. END
SIDE
CERTIFICATE OF'E1(EMP`hON FROM WORKERS' COMPENSATION INSURANCE: •This'section need not becompleted it .
the permit: Is for ane'hundred ($t00) o, less. icertity that in the pertormance of the.work:for which, this per mit, Is
issued,,l shall not emplay.any.persooin any manner sous to become subject to the Workers' Compensation Laws of.
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certif tate of Exemption, you should becomesubject to the Workers'
Compensetionprovisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed "revoked.
DIVISION,OF INOUSTRIAL.SAFETY PERMI7 CERTIFICATION: -
❑ 1hereby certify that noexcavation five (5)ormore feet indepth into which aperson isrequired todesce.nd,Will be- -
made'in connection with work authof,we more orized by this permit; and that no building structure, scaffolding; falsework, or -
demolition or dismantlingthereill tithan thirty-six (38) feet high. (Chap 3.2, Grp 2 Art -2. Sec 341, Title 8,'
CAC.),,;, -
13 As owner4ulider; I will not employ anyone to'do work which -would require a permit from the Division of -
Industrial Safety, as,noted above, unless such person has a'permit to do such work fromdhat 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 permitis issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's, Address
,I certify that I have read this application and statethat the abovelnformation 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 andstate that
the information given is correct. I agree to comply with all state3aws and county ordinances relating3o, buidling
construction, and authorize a`representativi of the City of La Ouinta Department of Building. and Safetyto enter
upon the property for whichI Have applied for this permit for the purpose of making inspections. • ' .
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLIPRMT
,�ccr�iT f . a � '� •
Ll
TOTAL •
FEIE •
�%+!%
VALUATION1,3 �f (�
f'
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.
❑
OPON 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)
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 PiI
STREET NAME.
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final