001476 (SATT)Z7,
I
PERMIT APPLICATION
City o1 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.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions of Chapter 9
-(commencing with Section 7000) of Division 3of the Business and Professions Code, and my license Is in full force
and elfect.
License Class Lic.' Number
Date 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 3 of the Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (MOO.):
O I. as owner of the property, or my employees with wages as Meir 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 o1 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. If, however, the
building or improvemni 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 o1 sale.).
O 1, as owner o1 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 contractors) licensed pursuant to the
Contractor's License Law.).
O 1 am exempt under Sec. B. 6 P.C. (Attached Certificate).
Date 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. Q.
Policy No. Company
O Certified copy is hereby furnished.
O Certified Copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L, F, MI)
JL Ctnnstruction
ADDRESS
P.O. Box 173
CITY/COMkIMITY/STATE/ZIP
Nestor; CA 92053
JOB SITE ADDRESS/SPACE
CITY/COMMUIITY/STATE/ZI P -
La. to CA 92253
BOK
PAG
PRC
C
mach. Fee 37.00
TNM
RHO
SE
S
TRACT
19903
10��
FM Fee 5.46
MOD
SB
TRACT NAME
HORIZON PALMS
OWNER NAME (L. F. MI) General Management Co
CONTRACTOWFIRM NAME
J.L. Construction
ADDRESS
ablove
CM/COMMUNITY/STATE/ZIP
abpm
PHONE I
LICNC
With rn=mity t Department
ARC/ENG FIRM NAME
Michael Buccino Assoc.
ADDRESS
340 S. Farrell Dr. A212
CITY/COMMUNITY/STATE/ZIP
PalmSprings, CA 92262
PHONE I
LICNC I
323-7877
11
USE OF PERMIT
Single Family Dwelling
BL
ZON,
I
FSB
SSB
SSB
RSB
OFC
ZONE ORD I -
LOT SZ
END
- SIDE
the permit is for one hundred (E100) 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 deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 1 hereby certify that no excavation 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 Z Art 2, Sec341. Title 8,
C.A.C.)
O 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.
O Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: 1 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
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.) 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 h n `' r 7/,
Date
APPU"MT 0 0_1mix.. �2-2=85
S.F.D.
Pern>_i.t to construct 1247 sq. ft.
of
living area and 433 sq. ft. of garage
as per approved plans.
mach. Fee 37.00
Plan Check Fee 307.96
rnnst. Fee 367.00
60.18
FM Fee 5.46
.P11m,hing Fee 85.00
Tnfrastructure
862.60
105.72 DEP. PAID
756.88
* aareendmt
With rn=mity t Department
TOTAL °.
FEE
.862.60
M 1 1 7 4 J L 3 /) 6 8 g 6K
I
FINANCE VALUATION 77, 948.00