0636 (RPL)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
This permit becomes.void if work not commenced.wilhin 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of 180 days. .
AgPRE
CERTIFICATE OF EXEMPTION -FROM WORKERS'COMF_NSATIONINSURANCE: 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 that in the.performance of the work for which,this permit is
(commencing with Section7.000) 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=o as to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date - Applicant
Date Contractor.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should,become subject to the Workers', "
OWNER -BUILDER DECLARATION: I hereby alfirm•that I am exempt from the Ciintractor's:License Law for the
Compensation provisions of the Labor Code, you m /st forthwith comply with such provisions or this permit shall
following reason.fSec. 7031.5. Business and Professions,Gode: Any city.or county.which requires.a.permit to
be deemed revoked. '
construct, alter, improve, demolish, orrepair any structure; prior to. its issuance; also'requires the applicant for
— DIVISION OF INDUSTRIAL SAFETY. PERMIT CERTIFICATION:
such permit to file.a signed statement -that he is licensed pursuant to the proyisions of the Contractor's License Law .,
- '0' 1 herebycertify that no excavation five (5) or momrfeel irfdepth into which a person is required to descend, will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that he is exempt
nrade.in connection with work authorized by this pe mit, and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged exemption. Any violation of Section"7031.5.by any applicant for a permit;
than.five hundred dollars MOb:):
demolition or dismantling thereof, will be more than :hirty-six (36)feet high. (Chap 3.2, Grp 2; Art 2, Sec341, Title 8,
subjects the applicant to a civil penalty,of not more
C.A.C.) r'
❑ 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 so workwhich would require a permit'from the Division of
". structure is not intended or offered" for sale (Sec'. 7044, Business and Professions Code: The Contractor's .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
"through his own employees, provided that such improvements are not intended or offered for sale. If however, the
Cf Division of Industrial Safety Permit No:
:building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that.
Date Applicant
he did not build or improve for the purpose.ofsale.):
.4.'19 -
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencyforthe performance. -
❑ I, as owner, of the property, am exculsively contracting withficensed contractors to construct the project (Sec>
of the work for which this permit is issued;(Sec. 3x97; 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.
FSB
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 teat the above information is correct. I agree to comply with all
Date " Owner
city and county ordinances and state laws relating 4 building construction., and hereby authorize representatives
ZONE ORD N, -,
'of this county to enter upon the above=mentioned aoperty for inspectiorr purposes.
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:'38W. Lab., C.).
Signature of Applicant or Agent ' Date. "
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIOhOFENTRY:IcertifyIhave read this application and state that "
O,Ger'if, If coy is hereby lurnished:,
the information given is correct, I agree to comply vithalfstate laws and county'ordinances relating to buidling'
❑ Certilled co_py'is lited vAthrthe City Building Inspection Department oVCdyr Department.
construction,' and authorize a *representative of the City of La Ouinta Department of Building and.Satety to enter -
3r v� ,
Date/ l i1 0 APPlicanl/k .0 [A s �?�1n� NY
'upon the property for which I have applied for.thie permit for.the'purpose.ot making inspections..
w -..
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPt/PRMT �• -> DDA
AgPRE
CITY,/COM MUNITY/STIA,T,E//ZZIP �
J"'/ S E'A'. ROES ACE /1. 60AI/ / ,•
/•
CITY/COMMUNITY/STATE/ZIP •.
_ •PAG
'
PRCTCS/
TWN.
FIND
SE
S
,BOK
^: TOTAL
FEE •
Se
TRACT NAME
OWNER NAME (L. F. MI) -
CONTRACTOR -FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE/
YVV J
LICNC I��i/{
cN O,
J
ARC/ENG FIRM NAME ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
•
LICNC
USE OF PERMIT
.81.
'
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N, -,
LOT SZ -'
END -
SIDE' •,
Print Applicant/Agent Name
APPt/PRMT �• -> DDA
i7" T 0/Ae'STrAG[ SPA iq 5
02
d
^: TOTAL
FEE •
VALUATION ; 4019. 060,
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 WaR
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final
10A
f=ireplace T.O.
❑
NO
ADDITIONAL INFORMATION
d
%� /// ✓
-
_
'
•-
'
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)
126 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
"
STREET NAME
P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30" Fixtures
31 Service
32 Final