0612 (RPL)PERMIT APPLICATION
City of La Duinta
Department
of Building and Safety
JOB�SIT A- _56 A^CE /IS�,� 6 Aj /( %J
V CJ-
CITY/COMMUN�/STAT✓E21P .
711
This permit becomes void it work not commenced. within 180 days from date
of issuance, OR, if work has been suspended or abandoned fora period of 180 days.
a
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSFTION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION:: I hereby affirm that l •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 Section 7000) of Division 3 of the Business and Professions Code, and my.license is in full force '
r ' issued, I shall not employ any person in any manner so as.o become subject tothe Workers' Compensation Laws of .
and effect.
California.
License Class. Lic. Number
Date Applicant
Date Contractor
NOTICE TO APPLICANT: If;,.after making this Certificate cf Exemption,.you should.become subject to the-Workers'r.
OWNER -BUILDER DECLARATION: I hereoy.affirm that I am exempt 1rom.the Contractor's License Law for the ..
^ Compensation provisions of the Labor. Code, you must tr rthwith comply with such provisions or this permit shall
be deemed revokeb.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
OWNER NAME (L. F. MI) '
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for .
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATIt N:.. ,
such permit to file a signed -statement that he is licensed pursuant to the provisions of the Contractor's License Law. •-
.01 hereby certify that no excaVati6n five (5) or more feetin depthinI6 which a person is required to descend, will bd -
(Chapter 9(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 thealleged exemption. Any violation of Section 7091,5 by any applicant for a permit•
demolitiontor dismantling thereof, will be more than thirty. -six (36) feet high.•(Chap 3.2. Grp 2, Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): -
C.A.Ca)^ ••
0 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, I will not employ anyone to do work which would require a permit from the Division of P
'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 ias 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.
r -
through his own employees, provided that such improvements are not intended or offered for sale. It; however, the
.0 Division, of Industrial Safety Permit No..
;building or i mprovemnt is sold within 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 there is a construction lending agency for the performance
0 1, as owner of the property, am exculsively contracting with licensed contractors to construct the.project (Sec: ,,
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.
Lenders 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 I, am exempt under Sec. B. 8 P.C. (Attached Certificate):
I certify that I have read this application and slate thadhe above information is correct. I agree to comply with all .. ,
''I
Date Owner '
city and county ordinances and state laws relaling.to tJilding construction, and hereby authorize representatives
.
of this county to enter upon the above-mentioned'prcperty for inspection purposes.- I
' 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.).
Signature of Applicant or Agent Date „
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION LIF ENTRY: I certify I have read this application and state that
O Certified copy is hereby furnished. ..
. .the information given is correcL.I agree to comply wi h all state laws and county ordinances relating to buidling
0 Certified copy I tiled with the City Building Inspection DII p hment or City Department.
.
• / -
construction, and authorize,a'representative of the C.ty of Ca Duinta Department of Building and Safety to enter
upon the property for. which I have applied for this prmit for the purpose of making inspections.
f Applicant r it 7 ..;.:�
Dates r ft!
Signature of Applicant or Agent Date
APPr/WAY I �V/V A•G A�
AODFtES
C1;VC iyIXUNLTY/STA7ZIP
/
JOB�SIT A- _56 A^CE /IS�,� 6 Aj /( %J
V CJ-
CITY/COMMUN�/STAT✓E21P .
711
BOK
PAG.-
'PRC
C
TWN
FIND
SE •[S
�AC,TO��_
LOT
!
MOD
SB
- V E, 0
TRACT NAME ..
OWNER NAME (L. F. MI) '
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ^'
.�y�
.�� oyyS
TOTAL
FEE •
ARC/ENG FIRM NAME - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC.11
-
USE OF PERMIT ,
BL
ZON
-FSB-
SSB
SSB
RSB
OFC
' -ZONE ORD • !•
'LOT. SZ' •.
.END
-SIDE
Print•Applicant/Agent Name
/
APPL/PRMT � 'GATE
619
/a
/1�✓_*507a946
A
- V E, 0
10 . ®.
fib all
:i
M �
w
�
TOTAL
FEE •
O
BLDG. DEPT.
VALUATION F g—
�'�C"%
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTQR-,
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.
❑
NPON ADDITIONAL INFORMATION
t4 -
'
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/L PiI
_... _
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring.
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service •
32 Final