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 '
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CITY/COMMUNITY/STATE/ZIP. .
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PRC
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LOT
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TRACT NAME
OWNER NAME (L, F. MI) ^- - -
CONTRACTOR -FIRM NAME ...... -
ADDRESS -
CITY/COMMUNITY/STATE/ZIP -.
PHONE •
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'LICNC
32v YyS
ARC/ENG FIRM NAME -- '
ADDRESS '
CITY/COMMUNITY/STATE/ZIP - '-
PHONE •
LICNC •
USE OF PERMIT ..
BL
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FSB
'SSB
SSS •
RSB
OFC.
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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