SFD (0460)77233 Calle Mazatlan
0460
APP L•IC
,ADDRESS
po 00 Box 780'
PERMIT APPLICATION
• City of La
Department of Building
Ouinla
and Safety• t
BOK I
PAG
This, permit becomes void if work not commenced within laO days from.date of issuance. OR; if -work has been suspended or abandoned for a.periodof 180 days.
C
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:.• This section need not be completed if
AICENSED CONTRACTORS DECLARATION: I hereby affirm .that I am licensed under provisions of Chapter -1
.the permit, is for one hundred (SIOO) o, less: Icertify 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, I shall not -employ any person in any manner so as to become.subject totheWorkers'-Compensation Laws of -
and effect.
California.
License Class Lic..Number,
Date -.App!ica-nt
'Date Contractor-
NOTICE TO APPLICANT:, If..after making this Certificali of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby 'aftirm'thal I`Sm exempt 66m the e6lriiract r;'s License Law for the
Compensation provisions of the Labor Code; you In st 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 diemed revoked,
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicanttor,DIVISION
OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed,statement that he is licensed pursuant to the provisions ofthef;onlractors.License Law
I hereby cerlifi that no excavation five (5) orhbre feet in depth into whicha person is required to descend,'will be AL
(Chapter 9 (commencing with section. 7000) of Division 3 ollthe Business and Professions Code) orj1hat he is exempt
made in connection with 'Work authorized by this permit, and thit no building structure, scaffolding; falsework: or
therefrom and the basis for the alleged exemption: Any violationof Section 7031.5 by any applicant fora -permit.,
'demdlition or dismantling thereof, will,be more than thirty-six (36) feet high: (Chap 3.2, Grp Z Art 2, Sec34I.Titlell,
subjects the applicant to a civil penalty of not more -than five hundred -dollars ($500.):
CITY/COMMUNITY/STATE/ZIP
0.1. as owner.oi the property, or my employees with wages as thei r sole compensation, will do the work; and the,
.-0 As owner-buildef, I will not employ anyone7to do Work which 'would require'a, permit from the Division of
structure isnot intended.or offered for sale.Sec. 7044. iiusiness,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,
OL
-through his own employees. provided that such improvements are not intended or offered for sale. If, however; the,,',
O,Division.6f.-Industr-ial.Safe.ty Pe.rm,i0o.
buildingor improverrint JSLSold within one year of completion. the owner -builder will have the burden of.pioving that
Date -Applicant,
he did not build orimprove, for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm' that there is a construction lending agency fo the',`performance .
0 1, 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 Coder The Contractor's License Law does not apply.to an owner of property who
I
Lende(s Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the.
Contractor's License Law.).
Lender's Address
0 1 am exempt under, Sec. ..-B. & P.C..(Altached Certificate)
I certifythat I Bove read this application state that the above information is correct. I agree to.comply with all-
Ownr
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: 1hereby affirm that I have a certificate of consent to self.insure, ora
certificate of Workers' Compensation Insurance f or a certified copy,thereof (Sec: 3800. Lab. C.).
Signature of Applicant or Agent' AL. 7
Date
Policy No.- .Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF1NTRY` I certify I have read this application and state that
0 Certified copy is hereby furnished.
is filed the!Cilr B.ilding Inspection Department/or C Department.
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 Quinta Department of Building and Safety to enter,
t-121..Certified-6opy with
14
Date ApplicantP 1VVC1b1
upon the.property or whichf'hav'e applied for this,p6irmit for purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APP L•IC
,ADDRESS
po 00 Box 780'
,2TOMMU NITYIST to ATEtZIP
A= ,r CA 92253.'
JOB SITE ADDRESS/.SPACE
77-233 CaUe Mazatlan
CITY/COMMUNITY/STATE/ZIP
La..Qulnta, CA 92253
BOK I
PAG
PRC
C
-
TNM
RNG'
SE
S
TRACT
144964
LOTMOD
192
8,93
Pluinbinq.Fee
G-1
SO
450"00'
TRACT NAME
Santa How Q:ym
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME
Sam As Abom
ADDRESS
'
CITY/COMMUNITY/STATE/ZIP
PHONE ILICNC
564-1315 1
'1333762
0
1—
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC 0
TOTAL e'
FEE '
USE OF PERMIT
S1 P./b with, Attached Gam-ge.
OL
ZON
FSO
SSB
SSB
RSB
OFC
ZONE ORD 0
fy LOT SZ
END
SIDE
APPUPRMTDATE
n4GO'12-28-83 S'/F/D
Peinit to Oonstnwt 2,758
Sq, Ft, of SlIFF/D
with Attached Garage
Fee
.26.00
Plan Check Fbe
326;95
.Canstructilon Fee
50900
Xical Fee
42,16
SK Fee
8,93
Pluinbinq.Fee
73,'00
Property Dev'L, ft Fee
450"00'
R E C E [1 V E D
N
A n,
G 9 RM
Ar H W
1^.4
e4vihp ei"
TOTAL e'
FEE '
$1,430,04.
4-BLDG.'DEPT.
J,
VALUATION
1$127,658i=8G.aF
-
Ah Ah
NO.
OPERATION TE
INSPECTOR
NO.
OP . TION DATE INSPECT Z
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
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.
❑
OWN
NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
t2 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APP OVALS
15 Ground Plumb 27
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire -
29B Bonding "`-
30 Fixtures
31 Service
32 Final