000994 (SFD):-7 '_T,� 7, .1.
PERMIT APPLICATION
City of La Quinta
Department of Building and Safety
JOB SITE ADDRESS/SPAC.
17-250 Avenida Fernathdo
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
This permit becomes void if work not commenced within 1110 days from date of
issuance. OR, if work has been suspended or abandoned for a period of 180 days.
1 b:: .
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:- This section need not be completed if.
,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 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 to the Workers'Compensation Laws of
'and effect.
California.
License Class L. c. Qm b e r
Date Applicant
.:Date' %Contracto - 1A
NOTICE TO APPLICANT: If, aftegrnaking this Cer.lificate'of Exemption, you should become subject to the Workers" -
OWNER -BUILDER DECLARATION: I hereby affirmAhat I am exempt from the Contractor's License Law for the .be
Compensation provisions of the Labor Code, you must forthwith complywith such provisions or this permit shall
deem(ed� revoked.'
following reason (Sec. 7031.5. Business and Professions Code: Any city,or county which requires a permit to
OWNER NAME (L. F. MI) Anden
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
•such permit to file a signed statement that he is licensed pursuant to the,provisions of the Contractor's License Law
0 .1 hereby certify that no excavationfive (5) or more feet in depthinto which a person is required todescend,will be -
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code)or that heisexempt
made in connection With work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom an ' If the basis for the alleged exemption. Any violation of.Sectio.n,7031.5 by any applicant fora permit
demolition or dismantling thereof, will be more than thirty-six (36),feet high. (Chap 3.2, Grp 2, Art 2, Sec341.-TitIe8,`
subjects the applicant to a civil penalty of not more than live hundred dollars ($500.):
C.A.C.) ' f , -
0 I. as owner of.the property, or my employees, withwages 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, or improves thereon, and who does such work -himself or -
BL
through his own employees. provided that such improvements are not intendedor offered for sale. If; however,,the
0 Division of Industrial Safety Permit No.
building or improvemnt is sold within one year of complkki�oq. the ow.ner-builder will have the burden of proving that
Date Applicant -
he did not b.uild.or improve for the purpose ofsale.). !,,: ,
CONSTRUCTION -LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
11 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 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
0 1 am exempt under Sec. B. & 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
o
city-and,county.�'dinances and state laws relating to building construction, and hereby authorize representatives
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
Of I =Is c ty o enter-upor rposes.
this I I i the above-mentioned property for inspection pu
V, Z
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3900. Lab. -C.).
SignatueLof,Applicant or Agent Date
Policy No Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY I certify I have read this application and state that
0 Certified copy, is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances -relating to buidling
0 Certified copy is filed with the City Building Inspection Department or City Department.
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. -
Date Applicant
Signature of Applicant or Agent Date
•
Print Applicant/Agent Name
APPLICANT NAME (L. F. MI)
xrem cmp,
ADDRESS
P.O. am 780
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
JOB SITE ADDRESS/SPAC.
17-250 Avenida Fernathdo
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
BOK
PAG
PRC
C
TWN -
RNG
SE
S
TRACTLOT
14496-
64
Const. Fee
503.00
MOD
G-1
S.
SMI Fee
TRACT NAME
Santa F43 C&4e
OWNER NAME (L. F. MI) Anden
CONTRACTOR -FIRM NAME. d
en
ADDRESS An
BM
CITY/COMMUNITY/STATE/ZIP
above
PHONE'
5614-331.5 1
CITY OF LA3UINTA
BUILDING DEPARTMENT
LICNC
1333762
ARC/ENG FIRM NAME. Barry Berjois
ADDRESS
1531 Chapala Street
CITY/COMMUNITY/STATE/IIP
Santa Barbara, CA, 93101
PHONE # F
805 963-8901
I
LICNC 0
USE OF. PERMIT
single family dwellim
BL
ZON
FSB
I SSB I
SS.
RSB
I I
OFC
ZONE ORD M
LOT SZ
END
SIDE
APPUPRMTDATE
11_n".q941
84�. S.F.D.
Pamift to omstruct 2,758 sq. ft. of
single fad ly dwelling with attached
qaraqe,
Mech. Fee
26.00
Plan Check Fbe
326.95
Const. Fee
503.00
Elect. Fee
42.16
SMI Fee
8.93.
Plumbing Fee
73.00f'-
Prm. Devel. Fee
T 2
CITY OF LA3UINTA
BUILDING DEPARTMENT
Al 11
._& U
I �V JAr"
TOTAL
FEE
1 -410 -OA
VALUATION 1 127.658.80
NO.
OPERATION ATE JNSPECTOR
NO.
,., ,OP ATION DATE' INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs &'Frms
34
Plenums & Ducts
2A
Slab Grade
3
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.
❑
NPON
ADDITIONAL,IN FORMATION
.
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
F INSULATION Thick Value
7A Walls (Batts)
12B ;Ceiling (Batts)
12C Ceiling (Blown)
14 Final '
; PLUMBING APPROVALS
15 Ground Plumb r 21-71f,:5-
_
16 > Water Piping
17 Rough Plumb
18 Vents
19 , Sewage Disposal
20 Sewer 7
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
fits
6
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
,
P/L P/I
\
STREET NAME
Power Pole
27 Conduit
28 .• Service Entrance
29 .i- ' :,yVir.ing
Grou- :Wire
296 Bonding
30 Fixtures
31 Service
32 Final