0394 (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,fora period of 180 days.
:.+.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION 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.forrene hundred ($100) o. IessA 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 lull force
issued, I shall not.employ any person inany mannersoasto become subject tothe Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date Contractor : ,
r -NOTICE TO APPLICANT: If, after making this Certificate of Exemption, 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
Compensation provisions of the Labor Code, you must forthwith comply.with,such provisions or this permit shall
following.reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to ' •
.be deemed revoked:
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.asignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw : •
❑ 1 hereby certify ttfat no ekcavMion five (5) or more feet in depth into which a person is required to descend, will be
.(Chapter 9(commencing 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 .' .,.p,
- 'demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2 Art 2, Sec 341, Title 8. -
subjects the applicant to a civil penalty of not more than live hundred dollars ($500.):x•^^*
C.A.C.)
O I, as.owner of the property, or. my employees with wages as their sole compensation, will do the work, and the.
❑ 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, arid who does such work himself or
CITY/COMMUNITY/STATE/ZIP -
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the.
❑ Division of Industrial Safety Permit No.
•_. building orimprovemnfissold withinone year ofcompletion, the owner -builder wil I have the burden of proving that
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 agencyfor 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, 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
O 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..) agree to comply with all
'Date �' Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives)
LOT, SZ-
of this county to enter upon the above=mentioned property for inspection purposes. °
WORKERS' COMPENSATION DECLARATION: I hereby.affirm that) have a certificate of consent to self -insure. or a
certificate of Workers' Compensation Insurance: ora certified copy thereof (Sec.•3800. Lab. C.).• .
Policy No. Company
O Certified copy is hereby furnished.
D Certified copy is filed itht e City Building Inspect' 0– ment'o(City ' Department.
Date �^�� Applicant ��fi4/,-,
AP�LI IET NAME_ E-(L..F. Ml) t Ta of CQ.i i
��!-�L'��T`t^p^�1-
ADDRESS .. _ ..
P. 0. Boli 1000
`rTI/a MQuinta, I CA 92253
JOBS ITE WODB�SS/SPAC., E , da
•OMM7U`/NI.TY/STATE�21P
CITY/COMMUNITY/STATE/ZIP
La Quinta, CA 92253
BOK
PAG
PRC
C
Plan Check Fee
TWN'
PING
SE
S
TRACT 765
LOT 1
LOT
7.60
Pltmi AM Fee
MOD
ER
SSB
�t 21
TRACT NAME, -'' w^
Werns Club
OWN. -ER NAME (l F. MI.) _ .• =,�=M of California
["'Y`-YY'7YYw1 GiMJA.61
CONTRACTOR-FIRM,•}pNNAMM'yE•1�y1`
-
ADDRESS
P. O. Box 1000
CITY/COMMUNITY/STATE/IIP
La Quinta, CA 92253
PHONE '
345-2888:
LICNC Y
413636
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE •
LICNC 0
us OF. T S/F/D W/AttacY�eci Garage
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD #,
LOT, SZ-
END
SIDE
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
APPVPRMT TE 3
R R m.i ✓A � 14A�1.� 83 Ccffb.
Permit Wild 2,382 Sq. Ft. of Q------ inifin
�t�o
i^,.
ge
Merha Ucal Fee $
28.50 '
Plan Check Fee
296.08
Cmistructim Fee
-455.50
Fitectri�cal Fee
37.51
SMI Fee
7.60
Pltmi AM Fee
71.00
Property D velopmlant Fee
450.00
t
® L. r-1983.
v BG� 0 La 0 -min -la
TOTAL
FEE
$1,346.19 '
BLDG.DEPT.
VALUATION $108,249.20
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 DeckL.o2
6zC�/
39 Appl. Clearance
7
Framing
a
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 INFORMATION
G
-711 O �} `- v
1V
19, $� C—LR U-11
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 l
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/L P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring b
29A Grounding Wire !i 7.
296 Bonding
30 Fixtures
31 Service
32 Final
STREET NAME