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0569 (RPL)PERMIT APPLICATION ' City of La Duinta Department of Building 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' COMP':NSATION INSURANCE: This section need not be completed -it - LICENSED CONTRACTORS' DECLARATION: 1• hereby affirm' that I 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 Sof the Business and Professions Code, and my license is in full force issued, I shall not employ any person in any manner E3 as to become subject to the Workers' Compensation Laws of . and effect. California. License Class Lic: Number Date Applicant - Date Contractor NOTICE TO APPLICANT: If, after•making this Certitic ate of Exemption, you should become subject to the Workers' 'r '•`' .• Compensation provisions of the Labor Code, you mLst torthwilWcomply with such provisions or this permit shall ; OWNER=BUILDER DECL'AR'ATION:. I hereby affirm that I.am exempt from the Contractor.•s License Law•for the be deemed revoked. following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a_permit.to . 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 4o file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law 01 hereby cirtity'that no eiliavation'five (5) or more eet in depth into which a person is reqdired to descend, will be (Chapter 9(commencing with section 7000) of Division 3 of the Business and,Protessions Code) orthat heis exempt made in connection with work authorized by this per mt, and that no building structure, scaffolding, falsework, or therefrom and the basis for the alleged exemption. Any violation of Section 7031 S:by'any applicant for a permit :' demolition or dismantling thereof, will be more than mirty-six (36) feet high: (Chap 3.2, Grp 2, Art 2, Sec341, Titleil, subjects the applicant to'a civil penalty of not more than five hundred dollars ($500.): C.A.C.) O.I. as owner. of the property; or my employees with wages•as their sole compensation, will do the work, and the' 0 As owner -builder; I!wilPnot employ anyone.to'co work which -Would require a permit from the Division' of structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Industrial Safety, as noted above, unless person has a permit to do such work from that division. Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or . ' 'through his own employees, provided that such improvements are not intended'ocoffered for sale. If, however, the 0 Division of Industrial.$afety Permit No. .building or improvemnt issoldwithin one year of completion, the owner -builder will have the burden of proving that. Date Applicant he did not build or improve for the purpose of sale.), CONSTRUCTION LENDING AGENCY: (hereby affirm flat there is a construction lending agency for the performance 0 1• as owner of the property, am•exculsively'contracting with licensed'contractors to construct the project (Sec: of the-workfor which'this-permit is issued, (Sec. -307, Civ. C'.). 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who 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 0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate). I -certify that I have read this application and state (fall the above information is correct. I agree to comply with all " Daowner te ' city and county ordinances and state laws relating t. building construction; and hereby authorize representatives ? of this county to enter upon the above-mentioned property for inspection 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. LabaC.). • Signature of Applicant or Agent • Date Policy No. Company CERTIFICATE OF COMPLIANCE AND AUTHORIZATIONIOF ENTRY: I certify I have read this application and state that ❑ Certified copy is hereby furnished. 1 the information given is correct: I agree to comply withalf state laws and county ordinances relating to buidling 0 Certified copy is'I ed'witli the City Building Inspection Department oriClt ^-Department.' construction, and authorize a'[epresentative of the City of La Duinta Department of Building and Safety to enter r` '', �� y.�'� upon the property for which I have applied for this permit for the Purpose of making inspections. Date / Applicant Signature of Applicant or Agent Date Print Applicant/Agent Name APPLICANT NAME ('F; i v/ ADDRESS 22 '051evei /// CITY/COMM UNIT TATE/ZIP - JOBSITEADDRESS/SPACE /' �• L ' 7TE- 4,/,4V%e CITY/COMMUNITY/STATE/ZIP. . BOK PAG PRC C. TWN RNG SE S TRACT L LOT ' MOD SB _ TRACT NAME OWNER NAME (L, F. MI) ^- - - CONTRACTOR -FIRM NAME ...... - ADDRESS - CITY/COMMUNITY/STATE/ZIP -. PHONE • ��- 72P d 'LICNC 32v YyS ARC/ENG FIRM NAME -- ' ADDRESS ' CITY/COMMUNITY/STATE/ZIP - '- PHONE • LICNC • USE OF PERMIT .. BL ZON FSB 'SSB SSS • RSB OFC. M • ZONE ORD I...-:; ;• LOT' SZ ' END SIDE APPVPRMT DATE U_ .Moe -le" - CPS .S.4Y% < P .SAO 11"MI-ole Cd�e s M • TOTAL . FEE VALUATION BI:DG. 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. ❑ 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 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 PiI STREET NAME 26 Power Pole 27 Conduit 28 Service Entrance 29 Wiring 29A Grounding Wire 29B Bonding 30 Fixtures 31 Service 32 Final