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PERMIT APPLICATION'
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City of
La Duinta. ,
- Department of Building, and Safety
This permit becomes void if work not commenced within 180 daysfrom date'of
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issuance,.OR, if Work has'been suspended or abandoned fora period -of 180 days:' ,
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CERTIFICATE OF -EXEMPTION FROM WORKERS'.COMPEN 3ATION 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.1 certify that in the performance of the work for which this permit is,' •.'.
11(commencing with Section 7000)of Division 3of the Business and Professions Code, and my license isin full force i - ,r. issued,+I shall not employ any. person i rfany manner�so Es to become subject to the Workers'Compensation Laws,of: '.
and effect.
California. . .
License Class Aic.,Number 1
Date Applicant
x' Date ' — % Contractor '-
NOTICE TO APPLICANT: If, after making this CertificatE of Exemption, you Should become subject to the,Workers,
1
.OWNER-BUILDERDECLARATION: I hereby altirm�that I•am exempt.fromthe Contractors License Law for the'.
;.• Compensatiomprovisions of the Labor Code, you musLforthwilh 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 CERTIFICATON:
such permit to filea signed statement that he islicensed pursuantto the provisions of the Contractor's License La`F ".
"&Iherebycertifythat noexcavation five (5)ormore feAindepth into which apersonisrequiredtodescend, will be''.
• _,(Chapter 9 (commencing with section 7070).ol Division 3 of the Business ono Professions Code) or that he isexempt
made in connection with woiK'authorized by this permi-, and that no building structure, scaffolding„falsework,Ar. :
` „therefrom and the basis for,lhe;alleged, exemption. Any violation o1, Sectio`o.7031:5 by any,applicant for a permit .,=I ,
:... demolition or dismantling thereof, will be more than thirty-six (36) feet high.'(Chap 3.2. Grp 2, Art 2, Sec34kr;Title8,
,subjects the applicant to a;civil;penalty of not more than live hundred dollars ($500.):. .
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U I, as owner of the property. or my employees with wages as their sole c)mpensation, will do the work, and the , .:
O As 'owne'r-builder, l will not employ anyone,to do work which would require a permit from the'Division of' ., • ..'
`.structure is notintended 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.
Industrial Safety,.as noted above, unless such person has•a permit to do such work from that division. '
' • through his own employees. provided that such improvements are not intended or offered for sale. lt however, 16
qa O Division of Industrial Safety Permit No.
• building orimprovemntissoldwithin one yearofcompletion, the owner -builder will have the burdenofprovingthat •'..,,
Date Applicant
he did not build ar improve for the purpose of sale.):,.. f <
CONSTRUCTION LENDING AGENCY: I hereby affirm thil there is a construction'lending agency for the performance
• -O I, as•ownerof the property, am exculsively contracting. with licensed contractors to construct the project (Sec. r
: • 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
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' builds or improves thereon, and who contracts for, such projects with 6 con traclor(s)'licensed pursuant to the.
-ers - - . . -, .
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.Contractor's License Law.).
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lender's Address
❑ I am exempt under. Sec. .•B. & P.C. (Attached Certificate). .' ,
I certify .that. 1 have read,this application and state thatAhe.above information is correcC I agree to comply with all
Date '' Owner' j ' '
city and county, ordinances and state laws relating to t ilding construction, andhereby authorize representatives
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• .WORKERS COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or.a .
of this county to enter upon the above'mentioned proDerty lot inspection purposes.
.
%certificate'o1.Workers' Compensation Insurance', or a certified;copy thereof (Sec. 3800: Lab. C.)._, ,', '•
Signature ol`dpplicant oYAgent Date
• Policy No. Company; ,
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- ❑ Certified copy is hereby furnished.. . . ; • .. !
kA • Ce lifted copy isdileA the C'(y Building Inspectio�n D�e artmen-t or Ci�" /' Department.: -..
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this applicationand state that c
the information given is correct. I agree to comply wits all state laws and county ordinances relating to-buidling ,
construction, and authorize a'representative of the City. of La Ouinta Department of Building and Safety to enter ,
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to
upon.the property for which h have applied for this permit for, the purpose of making inspections.
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Date Applicant
Signature of Applicant or Agent Date
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Print. Applicant/Agent Name
APPLICANT NAIr1E (L, F. MI)
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OWNER NAME IL. F, MI)0,_ zt
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a YALUATION ��-7
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
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.
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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 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 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