0501 (RPL)'APP •ICAN.T NAME, MI -
�i�. "01 i v'
PERMIT APPLICATION A
City of
La Duinta ;
Department of Building and Safety
PAG
PRC
-...,-This permit becomes Void if work not commenced within 180 days from date of
issuance, OR; if -work has bewsuspended or abandoned for a period of 180 days:' ' F
- - ;i'••.."- ...... "'
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPE9SATIONINSURANCE: This sectionneed not be completed if
' LICENSED CONTRACTORS. DECLARATION: I hereby affirm, that I am licensed'. under provisions'of Chapter' 9 • • .'
the permiuis for one hundred ($100) o, less. I certify hat in the performance of the work for which this permit is •=:
- (commencing with Section'.7000) of Division 3 of the Business:and.Prof essions Code, and my license is in.full force » -
-issued; I shall not employ any person inany manner seas to become subject to the Workers''Compensation Laws of .. .
• and effect: • ' . ., �t `�j .•,.CL
California. '
•License Class' I ic. Numtiet �/ - Y
Date Applicant.
Date — - Contractor - " �{ f -
NOTICE TO'APPLICANT: If,•after making this Certificate of Exemption; you should.become subject to the Workers: �,.
u•"
•OWNER-BUILDER'DECUARATION: •I hereby alfirmRhat Iain exempt from the Contractor's License'Law for the..., -,
Compensation provisions oflhe Labor Code, you must forthwith comply with'such provisions or this permit shall
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or.county which requires'a permit.to
r
' construct, alter, improve; -demolish; or repair any structure, prior to its issuance, also requires.the.applicant for . ,
DIVISION OF INDUSTRIAL. SAFETY PERMIT. CERTIFICATION: ,
-such permit to file a signed statement that he is licensed pursuanttotheprovisionsoftheContractor'sLicense.Law
0Aherebycertifythat noexcavationlive (5)oimore f,.et in depth into 'Whichapersonisrequired todescend,will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Cade) or that he is exempt ,
made in connection with work authorized by this pernit, and that no building structure; scaffolding, falsework, or
•- therefrom and the basis for thejalleged exemption. Any violation of Section 7031.5 by any appficantfor a permit
demolition or dismantling thereof, will more than thirty-six (36) feet high. (Chap 3.2..Grp2, Art 2. Sec341,.Title8.''
subjects the'applicanIto aicivil-penalty of not more than five hundred dollars ($500.):.- 1 -
— CAC:)'
O I, as owner of the property, or my employees with wages as theidsole compensation, willdo.the.work, and the -
p As owner•builder;i 'will.461 employ' anyone'to'd. work which would require a permit from the Division of ,
structure is. not intended or offered for sale.(Sec. 7044, -Business and ProfessionsCode: The Contractor's License
Industrial'Safely, as rioted above, uhless'such perscl has -a permit to do'such work from that division. "7 -
Law does not apply to an owner of property who builds; or improvesahereon, and who does such work himself or
.. ' ..t'
through his own employees, provided'that such improvements are not intended or offered for sale. f, however, the,
_ e:Division of Industrial Safety .Permit No.
building or improveritnt is sold within one year of completion, the owner builder will have the burden otproving that
Date Applicant r
he did not build or improve for the purpose of sale.):
CONSTRUCTION LENDING AGENCY: -1 hereby affirm th at 1,is a construction lending agency for the performance :
O I, as -owner of the property; ani exculsivefycontracting with licensed contractors to construct the.project (Sec.' • ...
of'the -work for which this permit is issued (Sec: 309, Civ: C.)Y• : •` -o
7044. Business and Professions Code:'The Contractor's License Law does not applyto an owner of property who'L'ender's
Name `
builds or improves thereon.'and who contracts for such projects with a contractors) licensed.pursuantto the-. .'
•
Contractor's License Law.).
Lender's Address
❑ I am,exempt under Sec. BY& P.C. (Attached.Certiticate)., -
I certify that I have.read this application and state thct the above information is correct. I agree to comply with all }
Date Owner
city and county ordinances and.state laws relating todwilding construction, and hereby authorize representatives
" -
of this county to enter"upon the above-mentioned pooperty for inspection purposes.
WORKERS'�COMPENSATION DECLARATION: 1 hereby affirm that I have a certificate of consehulo 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 3F ENTRY: ,I certify'I have read this application and state that "
0 Certified -copy is hereby furnished. .,. "�''-:. -
the information given is'correct: I'agree to comply w•th all state laws and county ordinances relating to buidling
O Certified'copy is.liled with the City.Building,lnspeciion Departmentor City Department ''
• .
construction, and authorize a representative of the _,ity of La Ouinta.Department of Building and Safety to enter . x
uponihe property for whichI have applied for this 3ermit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent — Date
_
Print Applicant/Agent Name
'APP •ICAN.T NAME, MI -
�i�. "01 i v'
CIT.Y/COMMUNITY/STATE/ZIP
JOB- SITE 3 _5 sce-A."r Z//S719 QA/ %/7
CI,T1�/COMMUNITY/STATE/ZIP " r
L.. H `rTJ
BOK -
PAG
PRC
C.
TWN
RNG
-SE
S'
��RIAyT�/ �•7
L0
7'
_•
MOD
SB
•'
TRACT NAME '
OWNER NAME (L. F. M1) .. . -
CONTRACTOR -FIRM NAME ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP . - - ,•
1
PHO
ARC/ENG FIRM NAME
'i
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE • ,-
•LICNC 0
USE OF PERMIT
BL
ZON
' FSB
- . SSB
SSB r.
RSB
OFC" :-
ZONE ORD N
. -LOT SZ
END
- SIDE'
VALUATION
BLDG. DEPT: _ ..
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.
❑
OP'NO.
ADDITIONAL INFORMATION
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
1'7 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 PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final