0442 (SFD)PERMIT APPLICATION
City of La Dug and 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.
PA P., IIC NJLME (L,_:. Ml) cn -
Lr�T�'CT'Y")�'��i
CERTIFICATE OF EXEMPTION FRO M.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 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,.l shall ngtemploy any person inany manner so 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 Certificate of Exemption, you should become,subject.to,the Workers'
OWNER -BUILDER DECLARATION:` I hereby affirm that I am. exempt from theCorltractor's license Law for the.
Compensation provisions of the Labor Code,.you.must forthwith comply with such provisions ar,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 CERTIFICATION:
such permit to tile a signed statement that he is licensed pursuant to the provisions.of the Contractor's License 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 he is exempt
made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or
therefrom at<d the. basis for -the alleged exemptionrAny violation of Section 7031.5 by any applicant fora permit
demolition or dismantling thereof; will be more,than thirty-six'(36) feet high. (Chap 3.2, Grp-2Art 2; Sec341, Title 8,
subjects;lhe applicant to a civil penalty of not more than five hundred dollars ($500.):
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
d 0 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 Contractor's License .
Industrial Safety; as,noted above, unless such person hasa permit to do such work from that division.
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. It, however, the:
v
" 0 Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner-builderwill;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 there 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 -the work for which.this permit is'issued (Sec. 3097, 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 oontractor(s) licensed pursuant to the .
Contractor's License Law.). _ _
Lender's Address
0 1 a exempt under Sec. B. B P.C. (Attached Certificate).
'I certify that I have,read this application and state that.the above information is correct.) agree to comply with all
DateOwner
city,and county ordinances and state laws relating to 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, or a
_ 1... 1 -
certificate of Workers' Compensation Insurance , or a'certified copy thereof (Sec. 3800. Lab. C.).
° Signature of Applicant or AgentDate
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify (have read thisapplicationand statethaf
0 Certified copy.is hereby furnished.
° f /
"
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. LaOuinta.Department of Building.and Safety to enter.
0?Ceilified_copy is fit d with th7Oity; Building Inspection Department orCity, Department.
) / -:.�; .. •� C.Y. _
—' upon the property for which I have applied, for this permit for the purpose of making inspections> - '
,Date Applicant'-
C pplicant
•
Signature of Applicant or Agent gate
Signature
PA P., IIC NJLME (L,_:. Ml) cn -
Lr�T�'CT'Y")�'��i
ADDRESS '
P. O. Elm 7€30
.CITV/COMMUNIta, CITY/COMMUNITY/STATE/ZIPLa A 92253
JOB SITE ADDRESSWACE
49-980 X�`ObregCn
CITY/COMMUNITY/STATE/ZIP
TE A
La al 92253 .
LJJGGii
BOK
PAG
PRC
C
TVM
FIND
SE
S
TRACT
14496-1
LOT
162
242.45
0ionstruction Fee
MOD
P-2
M3
F�ectical Feb, `. ,
TRACT NAME
Santa Rosa Cow
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NTRACTOR-FIRM NAME ..
AbSJY�''�'G
ADDAS
RESS '
CITY/COMMUNITY/STATE/ZIP
PHONE •
564-1315 1
LICNC 1
333762
Property Developuent Fee
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
USE OF PERMIT
S/F/D with Attached Garage
BL
ZON
FSB
SSB
SSB
RSB_
lop
OFC
ZONE ORD r,...
LOT SZ
TOTALFEE•
ENO'
' SIDE ,
Print Applicant/Agent Name
APPL/PRMT DATE
n447. 12.28-83
S/P/D
Pennit to cost ruct 1,812
Sq. Ft.
of S/F/D
with Attached Garage
Machanical Fee
$
31.00
Plan Check Fee
242.45
0ionstruction Fee
373.00
F�ectical Feb, `. ,
31.25
SE Fee
5.57
Plumbing Fee
48.50
Property Developuent Fee
300.00
r°
p1
.
lop
e
TOTALFEE•
7
VALUATIONI$ 79,103.20
BLDG.DEPT.
NO.
OPERATION D E
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
o
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.
❑
NPON ADDITIONAL INFORMATION
3 Si
�.
a� O
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R�
Value
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 S
25 Final
'
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P)I.
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final