0324 (SFD)APPLICAN- � T.NAM �0�t -
ILA
PERMIT
City
APPLICATION
of La Ownta . ` ���� �a �•
Department of
Building and Safety _ +.
This permit becomes void it -work, not commenced within 480 days from date
of issuance, OR; if work has been suspended or abandoned fora period' of 180 days. • ' . �•.
•
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATON INSURANCE:: This section need not be completed it"
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions,of Chapter 9 .
- the permit is for one hundred ($100) o, less. I certify; that it 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; l shall not employ any person. in any mannerso as.telbecome subject to the Workers'CompensationLaws of. -
and effect.
California.
License Class - Lic. _Number
Dale Applicant ,
.'Date. - Contractor ti o.
NOT,ICE•TO APPLICAN7,:,If, after making this Ceoificate:of :xemption, you should become subject -to the;Workers'
OWNER -BUILDER DECLARATION: I:hereby affirm that I am exempt from the Contractor's License Law for the
Compensatn provisions of the Labor Code, you•must for.Twith comply with,such provisions or this permit shall.. ,
be deemed revoioked. ;
following reason (Sec: 7031.5. Business and Professions Cade: Any. city or -county which requires a permit to
OWNER NAME (L. F. MI)
_ construct, after.- improve, itemolish,-or repair any structure.. prior to its issuance, also requires the applicant for
DIYISIDN.OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
,such permit,to4ileasignedstatement.thatheislicensedpursuanttotheproyisionsoftheContractor'sLicenselaw ..'r-
01 heietij certify that no dxcavation five (5yor more feel in depth into,which a person is required 16 descend, will be
(Chapter 9 (commencing with section 7000) of Division 3 o1 the Business and Professions Code) or that he is exempt
made in connection with woik authorized by.this,permit, and'that no building structure, scaffolding..falsework,or
.therefrom and the basis tor'the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit
demolition or dismantling thereof, will be more than,ihirty-six (36) leer high: (Chap 3.2, Grp 2 Art 2. Sec341. TitleB,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500:):
C.A.C:) �h - ,- ' ' ' ' ` ', ''=t cox: " ' - .
O I, as owner -of the property: or.my employees,with wages as their sole compensation, will do the work, and the •; ..
.-"'r' ,
f 9
❑ As owner•builder,' I will'not employ anyone'to do wok 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.hes a permit to do such work from that division.: -
Law does not apply io an owner of property who builds, or.improves thereon, and who does such work himself or
Ci Division_ Industrial Safety Permit No.
through his own employees, provided that such improvements are not intended of offered for sale. tf; however, the - . -
• , of
building orimprovemntissold within one yearofcompletion. the owner -builder will have the burden of proving that •,
Date Applicant•
he did not build or.improve for the purpose of sale.). a
,-.::CONSTRUCTION LENDING AGENCY: I hereby affirm that dere is a construction lending agency for the performance
❑ 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; Cv. Q.
7044. Business and Professions Code: The Contractors License Law does not apply.to an owner of property who '.
- Lender's Name .•
' builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the
Contractor's License Law.).
Lender's Address
❑ l am exempt under Sec. B.8 P.C.,(Attached.Certificate).
I certify that have -read this application and state lhat.tl^ above information is correct. I agree to comply with all ,
�*
' Date ' -Ownercity
and county ordinances and state laws relating to bui ding construction, and hereby authorize representatives: .
of this county to enter upon the above-mentioned propErty for inspection purposes. i
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a. ..
, .
' certificate otWorkers' Compensation Insurance', or a certified copy thereof (Sec. 3800: tab: C.). lr:; .
Signature'of Applicant or -Agent Date
Policy No Company, t
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF IINTRY: I certify l have read this application and statethat
• Certified copy is hereby furnished.��
01
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
,:b'Certified copy is,filed withdhRlly`Building Inspection Depart en for Department
, . ,
���y�( f� ,/, •. �� f . ( ��_
upon the property for which I have applied for this per nit for the purpose of making inspections.
Date , .. Applicant
Signature of Applicant or Agent Date _
APPLICAN- � T.NAM �0�t -
ILA
.. ,
ADDRESS0. Box 780
r:a/COMMUNITY/STATE/ZIP__,a,i.A
9225 '. .. ..
JOB SITE ADDRES&SPACE
V�Q.tta�.�
CITY/COMMUNITY/STATE/ZIP
� C A
La 92253
BOK
PAG
PRC
C
...
TWN.
RNG
SE
S
.TRACT -
14496-1
LOTMOO
181
.305.83 .
Cartetnxtion Fee
6-1
SB
`42.16
RAOT NAME Cbv6 '
OWNER NAME (L. F. MI)
M NAME
aeILOR� IRrporationt
7.CjONLjT
P.ESS
V.B� 780
YCI^Y/CVO ` MuMIL�X�Y/S r TES ' 92253 -
1619--564-1315
PHONE
9-A64 -1315 `
..- .
L c33762
.
ARRC/ENG FIRM NAME•
ADDRESS ,
CITY/COMMUNITY/STATE/ZIP. .. ^
PHONE tl
LICNC II
USE OF PER IThardi-
BL
ZON
-FSB,.
SSB
SSB::'
ASB
OFC
ZONE ORD •
_ LOT: SZ • .•
- END {i
' . SIDE
Print Applicant/Agent Name
APPL/PRMT _ �"� DATE
10-1043 f
Peimit toconstructModalG-1-B
Dwel.lkig .,,.2,296
Sq. Ft.
Garage ' ''462
-Sq. "'Ft,
Patio Raver 178
Sq. Ft.`,
mach. PGC -
23.00 r. -
Plan Check Fee
.305.83 .
Cartetnxtion Fee
.47040
'Flecttical Fel
`42.16
a1I Fee
8.02
Phan i..W Fee' "+
71.50 '
�'rtY Development Fee
450,00
.• , Y '
OTAL
Clay bf U Quint8. ' TFEE
$ 11371.01
BLDG: DEPT.
atm
VALUATION $ 114,066.99]"',
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
39 Appl. Clearance
7
Framing
f
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.
❑
NADDITIONAL INFORMATION
NO.
O.
r
�yJ0 Cir/� (�fJKL/
'J
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath12A
Drywall �(p !•
7
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
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 /!o Ir7fi•
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L 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