0615 (RPL)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
4
• This permit becomes void if work not commenced within 180 days'from date of issuance. OR, if work has been suspended or abandoned or a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions -of Chapter 9
(commencing'with Section 7000)'ol Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class
Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to .
construct, alter, impfove,'demolish: or repair any structure, prior to its issuance• also requires the applicant for
such permit to.file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law ..
(Chapter 91com mencing with section 7000) of Division 3 of the Business and Professions Code) or that.he is exempt
therefrom and the basis for the alleged exemption^Any violation of Section 717311.5 by any applicant for a.permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044. Business and.Professions Code: The Contractor's License
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. II, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve,(or the purpose of sale.).
0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
0 I am exempt under Sec. B.4 P.C. (Attached Certificate).
Date Owrier
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.).
Policy No. Company
0 Certified copy is hereby furnished. rs-
0 Certified copy is filed.with the City Building Inspection Department or City ` Department. .
Date—/-'/ Applicant
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TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME • '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
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ARC/ENG FIRM NAME
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CITY/COMMUNITY/STATE/ZIP '
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USE OF PERMIT
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SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS" COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in4he performance of the work for which this'permit is
issued. I shal I not employ any person•in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
'NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you mist forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation five (5) or more `eet in depth into which a person is required to descend, will be.
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than Thirty-six (36) feet high. (Chap 32, Grp 2, Art 2, Sec 341, Title 8,
C.A.C.)
0 As owner -builder, I will not employ anyone to •lo work which would require a permit from the Division of
Industrial Safety, as noted above, unless such permn has a permit to do such work from that division.
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0 Division of Industrial Safety Permit No...
DateApplicant
CONSTRUCTION LENDING AGENCY: I hereby affirm t rat there is a construction lending agency for the performance
of the work for which thW.permit is issued (Sec. 3097, Civ. C.).
Lender's Address
I certify that I have read this application and state flat the above information is correcLi agree to comply with all
city and county ordinances and state laws relating CI building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned Iroperty for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction• and authorize a representative of the City of La Duinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT n r i S DATE _SAA /f A
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TOTAL
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VALUATION 5 _9 • 0 6
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION
I DATE INSFtCTO.R
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.
❑
NO.
NO.
ADDITIONAL INFORMATION
w� 113
SEWAGE SYSTEM SIZE &' LOCATION
11 Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick "Ru
u e
Val
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
PSL
PROPERTY LINE
PiI
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service ,
32 Final
STREET NAME