0440 (SFD)• PERMIT APPLICATION
City of La Ouinta
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.
Yi . ..
—CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:.This section need not be completed if
LICENSED- CONTRACTORS DECLARATION- I 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 olthe work for which this permit is
(commencing with Section 7000) of,Division 3 of the Business and Professions Code: and my license is in lull force
issued, I shall not employ any person in any manner so•asto become subject to the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
,Date Contractor .._.-t
._.:;NOTICE-TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt.from the Contractor's License Law for the
Compensation provisions of the Labor Code, you must.forlhwith comply with such pravisions'or this permit shall
he deemed'revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county .which requires a permit to
so
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 tofile asigned statement thatheislicensed pursuant lothe provisions oftheContractor'sLicense Law
01 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
. (Chapter 9(commencing with section 7000).of Division.3 of the Business and Professions Code) or that heisexempt
made in connection with work authorized by this permit, and that building structure, scaffolding; falsework, or -
therefrom and the basis for the alleged exemption. Anyviolation of Section 7031.5 by any applicant.for a permit 4E
demolition or dismantling thereof, will be more,than than (36) feet high. (Chap 3.2, Grp 2, Art 2,.Sec341, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): ...�ali'�
C.A.C.)
0 I. as owner of the property.or my employees with wages as their sole compensation, will do the work, and the.
0 As owher•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 Contractor's License
Industrial Safety, as noted above, unless such 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
LICNC #
' through his own employees, provided -that such improvements are not intended or offered for saleAf, however, the
0 Division of Industrial Safety Permit No.
building orimprovemntissold within one year rofcompletion, 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: I hereby affirm that Ihere'is`a construction lending agency for the performance
0 I, as owner of the property am exculsively contracting with licensed contractors to construct the project (Sec.
of thework for which this permit is issued (Sec. 3097, Civ. C.). N
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
OFC
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 that the above information is correct. I agree to comply with all -
Dale Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
END ,.
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, or a
certificate of Workers' Compensation Insurance , ora-certified copylhereoI (Sec. 3800. Lab. C.).
Policy. No. Company,
0 Certified copy is hereby. furnished -
�O�itied copy,is'filed,with the Ifly lBuilding Inspection�qDeyl.lm�erifl r,City v D� apart _meet
Date 1 L (' / Applicant Y
APPLICANT NAME (L F MI) -
DRE
P•O. B= 780
CITV/COMTiTE/L�yP
�T uint A 92253
JOB SITE ADDRESStSPACE
49i -Tib 20 Qbregon
.C'ICOMr);�N�I`TV�/^T,TE/L�yP� 9243
d,
BOK
'PAG
PRO
C
Plan Check. Fee
TWN
RNG
SE.
S
1496-•1
`°160
7.39
Pluirbing F ,e
°3
so
450.00
TRACTCntNAL� RosaCove
OWNER NAME (L. F. MI)
Mp
COQ N'TSeR�ACTOAs�IRM bove
Above.ADDRESS
.
CITY/COMMUNITY/STATE/ZIP - -
64.1315
R �t I `.3�
ULU 91983
L1333762
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 0
$1,,311.34 v,
LICNC #
- •.
M
91F/Dwith Attached Garage
BL
I
I ZON
FSB,
SSB,
SSB .
RSB
OFC
ZONE ORD -M -
LOT SZ
END ,.
SIDE
r
Signature of Applicant or Agent Date
CERTIFICATE OF.•COMPLIANCE'AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction, and authorize a representative of the City of La Ouinta Department of Building and Safety to enter
upon the properry4or which 1 have applied for this permit for the purpose of making inspections..
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
. APPUPRMT { 1 4 4 1DATE
2,;"28-83
SIF D
Permit to construe 2,326 Sq. Ft. of S/F/D
with Attached Garage
Mechanical Fee $
31.00
Plan Check. Fee
291.20
Oonstzuctim Fee
448.00
�- ,Fee.
31.25
RU Fee
7.39
Pluirbing F ,e
52.50
Property DMelOpnEnt Fee
450.00
R �t I `.3�
ULU 91983
_ y
`TOTAL
FEE
$1,,311.34 v,
t: VALUATION $105,699.40•
BLDG. DEPT.
NO.
OPERATION D FE
INSPECTOR
NO.
OPE ION 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
Q
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.
❑
NP'N
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)
12CT Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb S�S
16 Water Piping
17 Rough Plumb /
18 Vents
19 Sewage Disposal
20 Sewer7-1
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 P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring // ,
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final