0610 (RPL)A7i%5"iyf iL `y.V SAS 5
AODR
791,
_ 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,leriod of 180,days:
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CERTIFICATE OF, EXEMPTION FROM WORKERS' COMPENSA. ION INSURANCE:.This section need not be completed if , .
LICENSED CONTRACTORS DECLARATION: I hereby affirm• thaVI am licensed under provisions. of Chapter-9
the.permil is for one hundred,($100) o, less. l:certify that In the.performance of the work.for which this -permit is
(commencing with Section -7000) of'Division 3 of the Business and.P.rofessions'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 -
and effect.
California.
'..License ClissLic. Number
Date Applicant '
Date - yContractor- ''_'
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
t,a• i - ' • •
OWNER -BUILDER DECLARATION: I'.4reby altlrtn',that. I'am exempt from the Contractor's'License Law for the ',
Compensation provisions of the Labor Code, you must to thwith comply with such provisions orthis permit shaIf r:� • •+
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code:.Any city or county 'which•requires a permit to
ADDRESS' ,. ••
construct, alter, improve: demolish, or repair any structure, prior to its issuance, also requires ihe,applicant for
.. „ DIVISION OF INDUSTRIAL SAFETY..PERMIT CERTIFICATION:,. 7
such permit tolileasignedstatementlhathe•islicensedpursuant tothe provisionsofthe Contractor'sLicenseLaw '
Olhereby ceitifythat noexcavation five (5)ormdiefeel in depth into which apersooisrequired todescend ,will be'-
.(Chapter 9(commencing.with section 7000) of Division 3 of the. Business and Professions Code) or that he isexempt,• . •
made in connection with work authorized by this permit, i nd that no 6uildind structure; scaffolding, falsework, or. '
therefrom and the basis for the alleged ;exemption. Any violation of Section 7031.5 by any applicant for ii -permit"
demolition orrdismantling thereof; wilt be more than thirty-six (36).feet high. (Chap 3.2, Grp 2; Art 2; Sec 341, Title B, _4,t.
subjects the applicant Ida, civil penalti,;of not more than five hundred dollars ($500.):• .-.
C A•C•) Tr&<5
O I, as owner of.the property. or: my employees with wages as their sole compensation, will do the work, and the
'•
:0 As owner+builder; Itwill'not employ anyone -to do w.rk which would require a permit from the Division of .
structure is not intended or, offeredtor 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 fromthat division., ..
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself -or
i
` Division
through his own•employees, provided that such improvements are not intended or offered for sale: If-, howevei; the '.
- 0 of Industrial Safety Permit No.
. -building or,improvemnt issoldwithin oneyearof completion, the owner -builder will have the burden ofprovingihat -• ..-
Date' Applicant
he did not build or improve for the purpose of sale.)... -
CONSTRUCTION LENDING AGENCY: I hereby affirm that there isa construction lending agency for the performance .
O J.,as owner of the property, am exculsively contracting with licensed contractors to construct the project,(Sec,, s,; '
of -the work for which this permit is issued (Sec:. 3097, 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
Contractor's License Law.). _- .
Lender's Address
.0:1 am exempt under Sec: B.' 8 P.C. (Attached Certificate)..
I certify that I'have read this application and state that the above.iniormation is correct: I agree to comply with all
Date "' Owner `' ,.
city and county ordinances and state.Iaws relating to buiding construction, and hereby authorize representatives ..
• WORKERS' COMP`ENSA710N OECLARATiON: I hereby at rm�fhat I haven certificate of.consem to self -insure: ora ,
of -this county to enter upon the above-mentioned property for inspection purposes.
' 'certificate of Workers' Compensation Insurance;. -ora certified copy thereof (Sec:=3800.:Lab.:C,).ro*.
`
�, w-• •
• Signature of Applicant or Agent Date
Policy No. Company,
CERTIFICATEOF COMPLIANCEAND AUTHORIZATION OF INTRi: 'I certify [have read this applicatiorfand state that '
❑Certified copy is hereby furnished. r.
a 2 ' •
the information given is correct. Iagree to comply with.sll state laws and county ordinances relating to buidlmg :..
'O Certified caps filed with the City Building Inspectid'n Department o City •' '�ODepartment.:
construction, and authorize a'representative.of the City. of La Ouinta Department of Building and Safety to enter
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upon the property for which.l.have•applied or this per nit for the purpose of making inspections.. +
Date . Applicant
- /
Signature of Applicant or Agent Date
3
+
Print Applicant/Agent Name ;J
A7i%5"iyf iL `y.V SAS 5
AODR
791,
CITY/COMMUNITY/ST ;E/LP
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C�1/TY/COMMU ,/DC7 /STATE/ZIP ..
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TRACT NAME
OWNER NAME (L. F. MI) .. ..
CONTRACTOR -FIRM NAME . ••
ADDRESS' ,. ••
CITY/COMMUNIITT/Y7/S^TATE/ZIP
PHOTAII
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP v., .,
PHONE M
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USE OF PERMIT
BL
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s VALUATION
BLDG. DEPT. — ; `
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECT61`1
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts '
2A
Slab Grade
35
Furnace Cornpart.
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.
❑
NON
ADDITIONAL INFORMATION
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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
P ,. P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring "y.:•. •..
29A Grounding Wire
29B Bonding
30 Fixtures `..y
31 Service
32 Final