0613 (RPL)PERMIT APPLICATION
r
.. City of La Duinta " -
APPUCAL7
Department of Building
�w
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. '
•
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENEATION INSURANCE: 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 th-t 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 • .
issued,.l shall not employ any person in anymannerso as to become subject.tothe Workers' Compensation Laws of .
and effect.
California. -
'• License Class Lic. Number
Date Applicant
- Tatee Contractor
NOTICE TO APPLICANT: If, after making this Certificate;ot•Exemption,,you.should become subject to the Workers'
affirm that I am -exempt from the Contractor's License law for thes
OWNER -BUILDER DECLARATION:, I hereby a
Compensation provisions of the Labor Code,ou must orthwith comply with such provisions or this permit shall
.
following reason (Sec. 7031.5. Business and Professions Code: Any. city or county which requires a permit to -
be deemed revoked., ,
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICAT'.ON:
such permit totileasigned statement that he is licensed pursuaht to the provisions of the Contractor's License Law'0IhirebycertifYthatnoexcavationfive(5)orrtiorefee:indepthintowhichaperisonisrequiredtodescend;willbe
ADDRESS
' (Chapter 9 (commencing with section 7000) of Division '3 of the Business and Professions Code)or that he is exempt
therefrom the basis for the: alleged exemption. Any violation of Section 7091.5 by any.applicant for a
made in'connection with work authorized by this perini , and that no building structure, scaffolding; falsework, or, - -
and permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500:):
demolition or dismantling thereof; will be more than thiRy=six (36) feet high. (Chap 3.2; Grp 2, Art 2, Sec341, Title8.
C.A.C.) - 'r ' • `�
❑. I. as,owner, of the -property. or my employees with wages as their'sofe compensation, will do the work, and the. - -
O As owner -builder, I will not employ anyone to do work which -.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, a"s 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
❑ Division of Industrial Safety eermit.No. -
building or improvernnt issoldwithin oneyearof completion, the owner -builder will havetheburdenofprovinglhat ..
Date' Applicant.
he did not build or improve for the purpose of sale;)s,
CONSTRUCTION LENDING AGENCY: I hereby affirm thal there is a construction lending agency for the performance..'
O. I, as owner of the property, am excufsively.coniracting with.licensed contractors to construct the project(Sec: -
- of the work for which this permit is issued (Sec. 3097 Civ. Q. -
7044.•Business and Professions,Code: The Contractor's License Law does not apply to an owner of property who -w
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
' 17.1 am.exempt.under Sec. B. & P.C. (Attached Certificate): ,. °
• I certify that I have read this application and state'thafthe above information is correct. I agree to comply with all ...
Date 'M Owner
city and county ordinances and state laws relating to t wilding construction, and hereby authorize representatives • _ .
'mentioned
of.this county to enter upon the above= prcperty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby atfirm.1hat I have a certificate of consent to'seltminsure, or a
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certificate of Workers' Compensation Insurance , or a certified copy.thereof (Sec; 3800. Lab. C.). a' .
Signature of Applicant or Agent Date'
Policy, No. Company
'CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:, I certify I have readthisapplication and ,state that- • '
.0 Certified -copy is hereby furnished .. ': :.
the information given is correct. I agree to comply win all state laws and county ordinances relating to buidling -
O Crtified•cbpy As filed with the City Building Inspection Department or City Department.
..construction, and authorize a'representativeof the City of La Ouinta Department of Building and Safety to enter
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l / t / • • �/Y)/iw 0 ;
upon the property for which I have applied for this permit for the purpose of making inspections.'
Date F APPlicant sf{ n�
Signature of Applicant or Agent Date
NAME (L
LS!(L -E MI) C .
ADDRESS .
CITY/C�6MUNIATY/STATE/ZIP_j�)��
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JOB SITEi11D+D�H��� STv 5 PfC��E
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CITYfY COMM! UNITY/ TATE/ZIP .
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TRACT
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MOD
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Ram C E! VIED
TRACT NAME
OWNER NAME (C. F,'Ml) - -
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP'
PHONE If"
-LICNC
ARC/ENG FIRM NAME -
ADDRESS•
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC II
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USE OF PERMIT -
BL
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SSB I
SSB. I
RSB
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ZONE ORD .
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"T' END.:
+ -SIDE
Print Applicant/Agent Name
• APPL/PRMT
DATE ?4
Ram C E! VIED
MAR 2 '1084
b City 13I LQ a
TOTAL'
FEE
6 A962
• VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPE.Q,—j
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.
0
OP'NO. ADDITIONAL INFORMATION
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:..
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick 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/I
STREET NAME
26 Power 'Pole.,
27 Conduit "
28 Service Entrance
29 Wiring.
29A Grounding Wire
29B Bonding
30 Fixtures
.31 Service
32 Final
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