0867 (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.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1' am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division lot the Business and Professions Code, and my license is in full force
and effect. }
fLicense Class ! Lic.-Number
Date �t Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
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
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9(commencing with section 7000) of Division lot the Business and Professions Code)or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500.):
❑ I. as owner of the property. or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License
Law does not apply to an owner of properly who builds, or improves thereon, and who does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
❑ 1, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
❑ l am exempt,under Sec. . B. 8 P.C. (Attached Certificate).
Date 1, Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure• or a
certificate o1 Workers' Compensation Insurance ,'or a certified copy thereof (Sec.'3800. Lab. C.). '
Policy No. Company
f Certified copy is hereby furnished. w
y[�J Certified copy is filed with the City Building Inspection Department orCity Department.
v _
Date a `.� ° Applicant
A
APPLICANT NAME (L. F. MI) '
B.nwiroe
ADDRESS
P.C. B= 1100
CITY/COMMUNITY/STATE/ZIP
la CS.inta, CA 92253
JOB SITE ADDRESS/SPACE
54-325 Qbreqm
CITY/COMMUNITY/STATE/ZIP '
Ia Qum* ta, CA 92253
BOK '
774
PAG
?41
PRC
315
C
Plan Ck. Fe 244.40
TWN
FIND
SE
S
TRACT
LOT
MOD
so
TRACT NAME '
OWNER NAME (L. F. MI( ppqq��.,.�,�..������
B. f'A°.JJ.iLA° e
CONTRACTOR -FIRM NAME
Rick Johnson Construct -ion
ADDRESS
53-740 Avenida Raa�
CITY/COMMUNITY/STATE/ZIP
La C2uinta CA 92251
PHONE .
LICNC 1
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
r
PHONE
LICNC •
'
USE OF PERMIT
Swale-farmly Awel-b=
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD •
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permitis for one hundred ($100) o, less. I certify that in the performanceof the work for which this permit is
issued, l shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ 1 h6reby certify that no excavaiion five'(5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this, permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2; Sec341, Title 8.
C.A.C.)
❑ As owner -builder, I will not employ anyone to'do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097. Civ. C.).
Lender's Name
Lender's Address
.l certify that I have read this application and state that the above information is correct. I agree to comply'with all
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.
Signature of Applicant or Agent Date
CERTIFICATE OFCOMPLIANCE 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 property for which I have applied for this permit for the purpose of making inspections.
Sigpature of Applicant or Agent Date
Print Applicant/Agent Name
fi
APPUPRMT DATE
URE
UR 7-24-34 S..D.
remit to construct 1592 sq. ft.
of single-family &ellincr and
91 sQ. ft. of porch and 430 sa. ft.
Of QaraQe as rer mmoved pian..
hbch• Fee 22.00
Plan Ck. Fe 244.40
Const. Fee 376.00
M. L t. ,, 43.13
N : 5.64
P1ino Fee 50.50
Prop, Fee 45 I00
G 1,191.67
`3 1250.00) Pd'. 7-16-84
01 %La Qu�� �' 941.67
TOTAL
FEE
941.67
BLDG. DEPT. VALUATION 80,628.80
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
11,39
Appl. Clearance
7
Framing
l
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
K7
�r Q ✓:{�
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb 6
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer Q
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 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
NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
�Subdivision Improvement Permit— Class III
DATE: /k4:�/�� Minor Improvement Permit Class IV y
LOCATION OF CONSTRUCTION __ 57 3,2 S" golg,,gEGOA
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION %%/1-/2,eIZAV 48,59&'A O
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN ;W2l'
Sketch (attach construction plans if appropriate)
0�1 ,t✓A�-iUE �o�y�>sGTED
,�rj/G Gi/� ��L� Gt/�v� f✓¢AD�,.p�
dAJ 440r17"
r�
APPROXIMATE TIME OF COMPLETION /10A:? I-- In
0( ESTIMATED CONSTRUCTION COST $ 13 '19 () •tom
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, defend and save the City, its authorized agents, officers, representatives andremployees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least tw e ty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this wgrkr
7 -
Name of Applicant (please print)
Signature of Applicant
Business Address
orf
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
IV
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I II ®�
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction cos
tfP-XTO
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty ���,,,..���'"""
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt.No.
Received by
Recorded by
$
Date "
CM", PERMIT VALIDATION
PERMIT NO. e'93 y
DATE APPROVED
EXPIRATION DATE
DATE ISSUED / ` �U 8�1
By'? 1A
Administrative Authority
TELEPHONE: (619) 564-2246