0573 (RPL)�` ,^,' .• - y PERMIT APPLICATION t +"
City
of La Duinta
'x. Department of Building and Safety, .•
CITY/COMMUNITY/STATE/ZIP "
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BOK
This permit becomes void if work.not commenced within 180 days -from date of issuance. OR, if work has been suspended;or abandoned Ior a period of -180 days.
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CERTIFICATE OF EXEMPTION FROM WORKERS' COME-NSATION INSURANCE? This section need not be completed it
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' LICENSED CONTRACTORS •DECLARATION: Ihereby affirm 'that ,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
issued. I shall not employ any person.in anymannec: Dasto become subject to.the Workers'CompensationLaws of..
and effect.
California
License Class - Lic. Number'
Date Applicant
' Date Contractor
.-NOTICE TO APPLICANT: It, after making this Certificwe'of Exemption, you should become subject.to the Workers;' .
F,
OWNER -BUILDER DECLARATION:• , Thereby affirm that tam'exempi from the Contractor s'License.Law for the • -
Compensation provisions of the Labor Code, you_,m ist'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
CONTRACTOR -FIRM NAME'.. .. - . ,• t,
construct: alter; improve: demolish, or repair any structure, prior -to its issuance, also requires the applicant for
DIVISION OF. INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permitto.file a signed statement that he is licensed,pursuant to the provisions of the Contractor's License Law ;'
.:.;'`OI'heribycertilythat noexcavation five (5) oimorefeetindepth into wAichaperson isrequiredtodescend, will be
(Chapter 9 (commencing with section 7000) of Division,3.of the Business and Professions Code) or that heis exempt
,:'madeinconnection*thworkauthorizedbythispenit,andthatnobuildingstructure. scaffold ingialsework:or
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit,:. '
demotition'or disinantling thereof; will be more than :hirty-six (36) feet high:'(Chap 3.2. Grp 2, Art 2; Sec341, Title8, `
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): •
C.A.C.)
O I, as ownerot the property, or employees with wages.as their sole campensation;.will do the work, and the
O As owner -builder, I will- not employ anyone to-lawork which would require a permit from 'Ihe' Division of {
• 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.
Industrial Safety, as noted above, unless such peredn has a'permit to do such work from that division..
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' through his own employees, provided that such improvements are not'intended or offered for sale. If, however, the
0 Division ol;lndustrial Safety Permit.No. e .
,building or improverrint is sold within one year of completion, the owner -builder willhave the burden of proving that ;
'Date Applicant
he did not build or improve for the purpose of sale.). '•
" CONSTRUCTIONLENDING AGENCY' I hereby affirm Liatthere is a construction lending agency foritie performance
O I, 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. 3197, Civ: C.): • r
7044, Business and Professions Code: The'Contractor's License Law does not apply to an owner of property who .
" Name
,b'uilps or improves thereon. and who contracts.for such projects with a contractor(s) licensed pursuant to the
;.Lender's
• Contractor's1icense Law:). - ... _
Lender's Address
O lam exempt under Sec: + B. 8 P.C. (Attached Certificate):.
I certify that l have read this application and state.t'rat the above information.in correct. I agree to comply with all,
' ' Ownerµ
city and county ordinances and state laws relating b building construction, and hereby authorize representatives
• _:Date
of this county to enter upon the above-mentioned:�roperty foPinspection purposes.
'WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have'a certificate of consent to self>insure, ora '
-. certificate of Workers' Compensation Insurance: or-a'certified-copy thereof (Sec. 3800.,Lab. C.). ":L -
Signature of Applicant or Agent Date
. • Policy,No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:: ('certify l have read this application and state that
❑Certified copy is hereby furnished. • a: '. r "
the *information given is'correct. I agree to comply with all. state laws and countyordinancesrelating to bufdlmg
O=Certifie'd�eopy is filed wl h the City Building Inspecho/n//Department,or City =' a �r'DBpartment.
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construction,. and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
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upon the property.lor which•( have applied for this permit for the purpose otmaking inspections. •-
Date ApplicantF
_. .
Signature of Applicant or Agent Date ;
Print Applicant/Agent Name
, at
APPLICANT NAME (L, F - MI)
ADDRESS .. ... :" -
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CITY/COMMUNITY/STATE/ZIPw �y `/A• nA
JOB SITE ADDRESS/SPACE " • -
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OWNER ME (Lt F, MI)
CONTRACTOR -FIRM NAME'.. .. - . ,• t,
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
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ARC/ENG FIRM NAME . • -
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ADDRESS -
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USE OF PERMIT • - . ,
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DATE
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BLOWDEPT.
VALUATION
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.
❑
NON 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
`
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
PSL PSI
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME