0567 (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 abandonec for a period of 180 days.
. .. -
CERTIFICATE OF EXEMPTION FROM WORKERS: COM'ENSATION INSURANCE: This section need not be completed if.
' LICENSED CONTRACTORS DECLAAATION:1 hereby 'affirm that Iani licensed .under provisions of,Chapter 9
the permitis 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 3of the Business and Professions Code, and my license is in full force .
i9sued,.1 shall not employ any person inany mannerso asto'become subject to the Workers' Compensation Laws of
and effect.
California.
License Class. Lic. Number
Date Applicant
• Date Contractor
NOTICE TO APPLICANT: IL after making this Certifi :ate of,Exemption;.you:should become subject to the Workers'
OWNER-BUILDEfi DECLARATION: I hereby affirm that I am exempt from the Contractor's License Lawlor. the
Compensation provisions of, the Labor Code, you (rust forthwith 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 CERTIFI�)ATION:
such permit.to file a signed statement that he is licensed pursyan1to the plovisions of the Contra ' ctor's License Law.01
hereby ce.rtifythat noexcavation five (5)ormdrifeetindepth into which apersonisrequired todescend,willbe'
'(Chapter 9 (commencing with section 7010) of Division 3 of the Business and Professions Code) or that heis exempt
made in connection with work authorized by this pE,,mit, and that no building structure, scaffolding, lalsework, or
therefrom and the basis for -the alleged exemption. Any violation of Section 7031.5 by applicant for a permit
demolition oi.dismantling thereof, will be more thartthirty-siZ(38) feet high: (Chap 3:2, Grp 2, Art 2. Sec 341; Title8,
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
O As owner -builder, I will not employ anyone to do 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 Contractors License
,Industrial Safeiy, as noted above, unless such peron has a permit to do such work from that division.- .
Law does notapply to an owner of property who builds, or improvesahereon, and who does such work himself or •
•
O Division ol.lndustrial Safety. Permit No.
• through his own employees, provided that such improvements are not intended or'otfered for sale. If, however; the.
:buildingor.improvemniissoldwithinoneyearofcompletion.theowner-builder will havetheburdenofprovingthat,
'Date a Applicant'
he did not build or improve for the purpose of sale.)r.
CONSTRUCTION LENDING AGENCY: I hereby affirm ,hat there is a.construction lending agency for the 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. 3997, Civ. Q.
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 - 7.
SSB
Contractor's License Law.)..
Lender's Address
O 1 am exempt under Sec. B:'8 P.C. (Attached Certificate).
I certify: that I have read this application and state that the above information is correct.4 agree to comply with all-
'" Date Owner ^ I .
city and county ordinances and state laws relating D building construction, and hereby authorize representatives
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of this county to enter upon the above-mentioned 3roperty for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of.consent to self -insure, or a
END
`•certificate'of Workers' Compensation Insurance , or certified copythereot (Sec. 3800. Lab. -C.)..
Signature of Applicant or Agent 'Date
Palicy.No. Company ,
- CERTIFICATE OF COMPLIANCE AND AUTHORIZATIOI.OF ENTRY: I certify I have read -this application and stati:ihat '
O Certified copy is hereby furnished. • • .f ''.the
' ment'.
information given is correct. I agree to comply uith'all state laws and county ordinances relating to'buidling
construction, and authorize a, representative of thr City of La Ouinta Department of.Building and Safety to enter
.O Certified copy Is 'led`wAthe-City Building Inspection Department or Cit .• ,Dem ppa
/ �� Ji :_ %d�/+�
upon the property for which l have applied for thi: permit Idr the purpose of -making inspections. .
Date Applicant
Signature of Applicant or Agent Date'
APPLIC NT NAME
ADDRESS
CITY/COMMON TY/STATE/ZI
JOB SITE ADDRESS/SPACE
Y9 -68S fa._ oni a.
CITY/COMMUNITY/STATE/Zip.. -
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PRC
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TRACT
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MOD
SB
TRACT NAME '
A_
OWNER NAME L. F, M1) -
CONTRACTOR -FIRM NAME •..
ADDRESS -.
CITY/COMMUNITY/STATE/ZIP - -
PHONE A
.� y6- v�o y
-
.3
LICNC 1
A
-
s
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE. 0'
LICNC N
'
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
ZONE ORD N
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'TOTAL"
FEE
END
SIDE.
Print Applicant/Agent Name
•APPL/PRMT i1. I ES �
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1.*5
37,ao
'TOTAL"
FEE
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
AppI.,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
Value aloe
7A Walls (Batts)
128 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 P1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
296 Bonding
30 Fixtures
31 Service
32 Final