000993 (SATT)PERMIT APPLICATION :`' _ `l •., ` ; pz,. ' ,
City of La Ouinta �. W
Department of Building and Safety
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
JOB SITE ADDRESS/SPACE
77-240 Avenida Fernamb
This permit becomes void if worknot commenced within 180 days from'date of
issuance. OR, it 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: I hereby affirm that [!am licensed .under provisions of Chapter. 9
the permit is for one hundred ($100) o•. less. I certify: that in the performance of the work'for which this permit is,
(commencing with Section 7000) of Division 3of-the Business and Professions Code andmy license is in full force
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of .
and effect. — 1
California. •'
License Class3 Llc Nu/tuber
Date Applicant
DateA / %� } Contractor —yam- � r�'�
_
.NOTICE TO AP.PLICANT:,If, atter making this Certificate of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: 'Thereby affirm that I am exempt from the Contractor's License Law for the;
Compensation provisions; of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or .county which requires a'permit to
OWNER NAME (L• F. MI)
Ander
'construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
N
such permit to file a signed statement that he is licensed pursuantto the provisions of the Contractor's License Law
01 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9lcommencing with section 7000) of. Division 3 of the Business and Professions Code)or that he is exempt
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom-and'the basis for the alleged,exemption. Any violation of Section 7031.5 by any applicant for a permit
demolition or dismantling thereof, will be -more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.) -• '
0 I. as owner of the property, or my employeeswith wages as their sole compensation, will do the work, and the
0 As owner -builder, I will not employ anyone to•do work 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 has a permit to,do such work from that division.
Law does not apply to an owner of property who builds, orimproves thereon, and who does such work himself or
7 '
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial.SatetyPermit.No,
building-orimprovemnt is sold within oneyear of completion, theowner-builder will havethe burden of provingthat
Date Applicant
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance •+./.;
0 ],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 Code: The Contractor's 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 contractor(s) licensed pursuant to the
Contractor's License Law.).
Lender's Address
a•.
0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date Owner '
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified Copy thereof (Sec. 3800. Lab. C.). -
Policy No. Company
O Certified copy is hereby furnished.
0 Certified copy is, filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI) .. '
Andgm
ADDRESS'-
P.O. Box 780
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
JOB SITE ADDRESS/SPACE
77-240 Avenida Fernamb
CITY/COMMUNITY/STATE/ZIP '
Ia, (WAnta. CA 92253
BOK
PAG
PRC
C
TWN
RNG
SE .':
S
TRACTLOT
l44 6-3
Const. Fee
63
Elect. Fee
MOD
Gr -3
,SB
3.39
TRACT NAME
Rnsacome
OWNER NAME (L• F. MI)
Ander
'CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 1
LICNC 0
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
.tial ci E�X�'1F# `7.�i1 c7.11
PHONE N
805 963-890.
LICNC M
TFEE
USE OF PERMIT 22.r,,_.'' ww r�
BL
ZON'
FSB SSB SSB RSB
OFC
ZONE ORD M
LOT SZ
END
SIDE
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 l have read this application and state that
the information given incorrectA,agree to comply with all state laws and county ordinances relating to buidling
/construction, and ktiiorize a'repiesentative of the City of La Ouinta. Department of Building and Safety to enter
upon the p�yopperty or}which.l-haves applied for this permit for the purpose of making inspections..
Signature o pl5plica'nt or Agent Date
Print Applicant/Agent Name
APPLJPRMT 0 Al 9q
3 ixlq-84 SLED.
Permit to crostrnct 2,326 sq. ft. of
family dwelling with attached
garage
`garage
Nisch. Fee
26.00
Plan Check Fee
291.20
Const. Fee
448.00
Elect. Fee
36.90
an Fee
3.39
Plumbing Fee
73.00
Prop. Devel. Fee
45Q.OQ
R CEIVE.
fX
TA
B
11,
_1
TFEE
1.332.49
BLDG. DEPT.
VALUATION 105,867.60,
'
Ah
r1,
NO.
OPERATION IIATE INSPECTOR
NO.'
OP ATION DATE INSPECTOR'
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
�~
2
Ftgs & Frms
34
Plenums•& Ducts
2A
Slab Grade
35
Furnace Compara.
3'
Steel a
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. ❑
NO
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & 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
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
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
, REAR OF PROPERTY LINE
.
P P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service. Entrance
29 Wiring ,jc.�.,��x--
29A Grounding Wire
29B Bonding
3U Fixtilres.: :.
31 Service
32 Final