0443 (SFD)certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
0 Certified copy, is hereby furnished.
1 -�
,,Certified 'copy is ffled,�vith(. �thef City Building InspectiomDepartmentee or�CltyV -+ •—DeDartmenC.
O / Applicant
APPLICANT �leatim
ADDRESS
P. U• Box vox 780 '
' PERMIT APPLICATION
City of La Duinta
Department of Building
and Safety
This permit becomes void if work not commenced within 180 days from dale of
issuance, OR, if.work.has been suspended.or abandoned for a period of:180 days.
-
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 permil-is for one.hundred ($100) o, less. I certifythat in the performance of the work for which thWpermit is :.
(commencing with' Section 7000) of Division 3of the Business and Professions Code, and my license is in full force
issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
and elfect.
California.
License Class Lic. Number
Date Applicant
• Date Contractor
NOTICE TO APPLICANT:. If, after making this Certifieate,of.Exemption,.you-should become subject to the Workers'
OWNER -BUILDER DECLARATION: 'I hereby affirm"that I am exeml; rdm the Contractor's License Law for the
Compensation provisions ot;the labor Code, you must 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
b. deemed revoked. •
construct, Mler'improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
.such permilto file asigped statement.thatheis licensed pursuant to the provJsions of the Contractor's License Law
0 hereby certily that no exdivatioh five I% 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, falsework, or
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
demolition or dismantling thereof, willbe more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title8,
subjects the applicant to a civil penally 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
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 has a permit to do such work from that division.
,Law does not apply to amowner of property who builds; or,improves thereon; a6d who does such work himself or
• '
through his own employees: provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial •Safety. Permit No.
building or improvemm is sold within one year of completion, the owner -builder will have the burdenofproving 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 lehdingagencyfor 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 town 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 1
Contractor's License Law.). _
Lender's Address
• • 0 1 am exempt under Sec. B. & 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
Date Owner
city and county ordinances and state laws relating tobuilding construction, and hereby authorize representatives
WORKERS' COMPENSATION'DECLARATION' I hereby'affirm that I have a certificate of consent to self -insure or a
of this county'to enter upon the above-mentioned Property for inspection purposes.
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
0 Certified copy, is hereby furnished.
1 -�
,,Certified 'copy is ffled,�vith(. �thef City Building InspectiomDepartmentee or�CltyV -+ •—DeDartmenC.
O / Applicant
APPLICANT �leatim
ADDRESS
P. U• Box vox 780 '
C,JTar/C MQ�MUNITY,_ ATEla 92253
4y =19ADDRESS/SPACE
5 Rt•T� °t'i1clda Gbregm
NI,Y�
/STATE/ZIPt
�1T'/CQ MU92253'
BOK
PAG
PRC
C -
Plan Check Fee.
TWN
RNG
SE
S
96-1
LOT
`°
5.85
Pltmtiin-a Fee
°1'
SO4
450;00
TRACT NAME
Santa lbs AVe
OWNER NAME (L. F. MI)
CONT,RAe AzFIRM NAME� -
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE6315
E
I, G 91983 L
`3x9762
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 1
LICNC II
USE Of�,ERMlAth. Attached Garage
BL
ZON
FSB
SSB
SSB
ASB
OFC
ZONE -ORD 0
7 1
LOT SZ
END
SIDE'.
1".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 Duinta Oepartment.of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
'Date
APPUPRMT n 4 /7 J 1-AT28-83
S/F/D
Permit, to a mstruct 1,903 Sq. Ft. of S/F/D
with Attached Garage
Mical Fee $
31,00
Plan Check Fee.
250.25
Gonstructcin Fee
385.00
Electrical Be.- ..
31.25
&a Fee
5.85
Pltmtiin-a Fee
48,50
Property Devlelogwent Fee
450;00
r
E
I, G 91983 L
TOTAL
FEE
$1,201.85
BLDG. DEPT.VALUATION $ 83t u ,�
- -
NO.
OPERATION U. E•
INSPECTOR
NO. OPER ION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
v�
,
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
+;j
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
r
/-7
d/ •�/
/ 1-2
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick alu
Value
7A. Walls (Batts)44e d
126 Ceiling (Batts)
12C Ceiling (Blown)
14 Final "9 ,
- 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 i�
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L 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
30