0355 (SFD)PERMIT APPLICATION
City of La Duinta
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 (CONTRACTORSDECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
• (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class Lia Number"
'Date Contractor" •-
OWNER -BUILDER DECLARATION: I"hereby affirm thatTam exempt. fro m the Untractor'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 3 o1 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 penalty of not more-than.five hundred dollars ($500.):
0 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 property 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. It, however, the
building or i mprovemnt 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).
0 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.). _-
0 1 am exempt under Sec.� B. 8 P.C. (Attached Certificate).
V15ate I /.i i ; • j Owner t IsN,.ti f '
0
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self assure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab.. Q. V
Policy No. Company
O Certified copy is hereby furnished.. - . _�, w . .
0 Certified copy is fijed with'ttie City Building Inspection Department or City' . Department.
Date Applicant
-
APPLICANT NAME (L MI)
ADDRESS
CII V/CGI NyQyITtiV/;TATQ �Z�I��P -
�92274
3 S4-E565E 7 P_ACw� Carranza
CI,LY�/COMMr yY91T9�Y�ta f /ZIPd �T 92253
�•i�
BOK
PAG
PRC
C
$'19100
TWN.
RNG
SE
S,
TRACT
LOT
SQA Plumbing Fee
58,00
MOD
SB
a
TRACT NAME
OWNER NAME (�l�F, MI -
anwe
CO TR�ACI�TOR-FIRM NAE.
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
I
PHONE t `
LICNC 8
ARC/ENG FIRM NAME "
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE M
LICNC M
USE OF PERMIT
Siml,e-Family Dwellim
BL
ZON
J
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 permit is for one hundred ($100) o. less. I certify.•that in the performance of the work for which this permit is
issued; I 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 Ifeemed'revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O' I hereby certify that no excavation five (S) 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 B,
C.A.C.)
0 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.
0 Division of Indusjrial.Safety Permit No.
,,.Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
ot.the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I 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 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 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 R l IIS! 11D_L_��
SFS
Pemit to eiuct 1,356 Sq.
Ft. Of
single -Family House
Mechanical Fee
$'19100
Plan Cock Fee
226.85
Omstructim Fee
354.01
Electrical Fee
31.45
SQA Plumbing Fee
58,00
Property Deve]O Ment Fee
300.00
a
NOV 2 W3
City of La Quinta
r%
[P vw TOTALFEE $ 989.31 y
r
+ VALUATION $ 71,696.40
BLDG. DEPT.
NO.
OPERATION •DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1'
Set'Back
33
Ventilation:System
2
Ftgs & Frms
oZ0
T
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36
"' `Inlets:& Outlets '
4
Grout Blocks
37
CombustionrAir•.
5
Bond Beams
18
Compressor
6
Roof Deck
5'
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.•
❑ SON4
T
43
Final
1.0A
fireplace T.O.
❑
OP'N
NO:
ADDITIONAL INFORMATION
✓/ V
SEWAGE SYSTEM.SIZ:E & LOCATION
11 Exterior Lath
12 .Internal Lath
12A Drywall
13 Finish -Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts) ,
12C Ceiling (Blown)
14 Final
PLUMB ING.APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer ci ,
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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B, Bonding
30 Fixtures
31 _ Service
32 Final
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL 36773
Received From ' M i �. • r `c Date:
Address: . ( �.!/' �� `t. e �•r' — ,i --...
Account No. Lot(s) r • Tract
Service Address e'
Mptprlg)
I 7, Service(s)
Rankflnw151
House Laterals)
Detector Check(S)
Meter Surcharge
�$anitation Capacity Charge % +°-
W.S.B.F.C.
C Temporary Construction Meter
Turn on Charge
C Uncollected Account - Name
Inspection Fee - Tract -
Fee -
Plan Check Fees Water I Sewer -
Tract -
Bond Payment - A.D. Bond
w
Assmt.
Customer Deposit
Other
Remarks:
Copy to:
Cash
Check
Money
Order
G.A. Code
$
TOTAL $
Water Service
Cashier -
�rt� CVWD-438 (11189)