0609 (RPL)7 "
ADD/,i(,JESS'
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PERMIT
APPLICATION
City of
La Duinla
Department of
Building and Safety'
C
This permit becomes void if work not commenced within 180:0ys1rom date of issuance, OR, if work has been suspended or abandoned for period of 180 days.
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENS_iTION INSURANCE: This section need not be completedif
LICENSED CONTRACTORS DECLARATION: I hereby. affirm that I am licensed under.. provisions. of Chapter 9
the permit is for one.hundred (5100) o. less: I certify tha in the performance of the.work'for.which this ftrmit'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 a=:to become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number. _
Date Applicant
Y
,: Date."-' • 'Contractor
:NOTICE TO APPLICANT: If, after making this Certificate cf Exemption, you should become subject to the Workers' •
"
OWN41 UILDER DECLARATION: �I hereby affirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you must 1••rthwith comply with such provisions or this permit shall .
be deemed revoked.
' following reason (Sec. 7031:5, Business and Professions Code: Any city or county which requires a permit to
PHONE
4/90
- 'construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for •
DIVISION=OF INDUSTRIAL SAFETY PERMIT CERTIFICATICN: .'
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor'sLicenseLaw '
"O Ihereby eertifythat'noexcavation five(5)6rmore feet 'ndepthinto which apersonisrequired.todescendiwill be,
(Chapter9(commencing with section 7000) of Division 3 of 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, falsework, or
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by applicant fora.permit
demolition of dismantling thereof, will belmore than thin+ -six (36) feet high. (Chap 3.2, Grp 2; Art 2, Sec341, TIIle8:
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): '
C.A.G.)
• O I, as owner of the property, or my employees with wages as their sole compensation: will do the work, and the " •
. • 'r] As owner -builder, I will 'not employ anyone'to do v%ork which would require a permit from. the Division of
structure isnot intended or offered for sale (Sec. 7044, Business and Professions Code:.The Contractor's License,
Industria] Safety, as noted above.'unless sucfi person' ILas 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 '
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through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial Safety Permit No., .
building orimprovemntissoldwithin one year -of completion, the owner -builder will have the burden of proving that
Date' Applicant' '
he did not build or improve for the purpose of sale.). :;•
•'
CONSTRUCTION LENDING AGENCY: I hereby affirm that Here is a construction'lending agency for the performance
❑ I, as owner of the property, am exculsively contracting with licensed contractors toconstruct the project (Sec.
of the work for which this perTnit is issued (Sec. 3097, -.iv. 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)'Iicens6d pursuant to -the.
✓� END' :'
Contractors License Law.)..
Lender's Address
•0!4 amexempt under Sec. B. & P.C. (Attached Certificate).:.. ,
'. I certify that I have read this application and state that fie above information•is correct. I agree to comply.with all
Date Owner w
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.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
- certificate of'Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800,.Lab. C.). sy
.
Signatore of Applicant or Agent Date
Policy No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF -NTRY: Ice.rtify.I have read this application and stafethaf =
❑ Certified copy is hereby furnished. ,
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
❑ Certilied�py.ls filed with the City Building Inspedio Department or.City -Department.' ' •
1. 1 r ,1
, , y/• f+ I f . �h•!
construction, and authorize a'representative of the Cit- of LaOuinta Department of Building and Safety to enter.
upon the property for which I have applied for this pernit for the purpose of making inspections. '
Date r} i ! Applicant t
Signature of Applicant or Agent Date
APPLIcH/,I/L v I SAL
ADD/,i(,JESS'
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CITY/COMG �Y/ TAT IL ✓C �I � p7
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TRACT NAME
OWNER NAME (L. F. MI)
.CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE
4/90
ARC/ENG FIRM NAME '
ADDRESS - -
CITY/COMMUNITY/STATE/ZIP
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USE OF PERMIT
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,SIDE '
Print Applicant/Agent Name
APPUPRMT' 19 � DATE 5 Ad ••
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:TOTAL
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VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE "t 4NSPECTC.
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 1 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
(-�\
0/
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
PI P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 .Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final