0299 (BLCK)r �
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.
LICENSED CONTRACTORS DECLARATION: I`hereby affirm that I am.licensed.under provisions of Chapter 9 -
(commencing with Section 7000) o1, Division 3 of the Business and Professions Code, and my license is in lull force a
and effect.
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 violation o1 Section 7031.5by any applicant for a permit.
subjects the applicant to a civil penalty of not more than five hundred.dollars (5500.):
O 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 Protessions.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. IL however, the
building or improvemnt is so Id 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.).
0 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.).
0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate)
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. 3810. Lab. C.). !rI
Policy No' Company
O,Certified copy is hereby furnished.
O Certified copy is filed with the City Building•Irispection Department Or City Department.
Date Applicant _.
APPLICANT NAME (L, F. MI) •_ •' r
ADDRESS -'
CITY/COMMUNITY/STATFJZIP
JOB SITE ADORESS/SPACE-•�, C '
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CITY/COMMUNITY/STATE/ZIP yy...
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME "
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ADDRESS!
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC M
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC
USE OF PERMIT
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SSB
SSB
RSB
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ZONE ORD •
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END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o. less: I certify that in -the performance of the work for which this permit is
issued, I shall not employ any person in any manner so a s to become subject to the;Workers' Compensalion Laws of
Californi '11"/
�� .Z .s /�!! Noe '
Date % Applicant
r
NOTICE TO APPLICANT: If, after making this Cert if Cate of -Exemption; you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwithcomply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 I hereby certify that no excavation five (5) or mese feet in depth into which a person is required to descend, will be
made in connection -with work authorized 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, Sec341, Title 8,
C.A.C.) AT y 1
0 -As owner -builder, 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 from that division.
O 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.).
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 n 7. R9, OAT
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TOTAL
FEE7"
AA
BLDG. DEPT. VALUATION
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING. APPROVALS
MECHANICAL. APPROVALS
1
Set Back
33
Vent ilatiomSystem
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
3&..
Compressor,
6
RooUDeck
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.
❑
OP'N' ADDITIONAL INFORMATION'
NO..
' .
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath.
12 .Internal Lath
12A Drywall,
13 Finish Grade
INSULATION Thick al
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/L
r
STREET NAME
26`' Power Pole
27 'Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30. Fixtures.
31 Service
32. F final