0391 (SATT)PERMIT APPLICATION
City of 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. '
ADDRESSPSj(,Oj•JE3YE�"�I(�XG1' 000"�0h
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,.lesstl 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.
i
California.
License Class Lic. Number
Date .Applicant.
Date ' ' Contractor
NOTICE TO'APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that 1 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
215.15
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 excavation 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) orthat 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, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
CAC) *'
O I. as owner of the property, or my employees with wages as their sole'compensation, will do the work, and the
'O 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
-
O Division of Industrial Safety Permit No.
through his own employees, provided that such improvements arenot intended or offered for sale. If, however, the
building orimprovemntissold within one year.ofcompletion, the owner -builder will have the burden of proving that -
Date" Applicant
he did not build or improve for the purpose of sale.). I'CONSTRUCTION
LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:.
of the work foe 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 theteon, and who contracts for such projects with.a conttactor(s) licensed pursuant to the
SSB:
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. I 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 I have a certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance'. or a certified copy thereof (Sec. 3800. Lab. C.).
.. Policy No. Company
•r,:�O Certified copy is hereby furnished. -
O Certified copy is filed-
dwith the City Building Inspection Depar"tr�ent/y� Any Department.
�`
Date / i' Applicant __� /W� A
AP-jP,'LiICAHT NAME F Mln , _ 1__ ___t y+M �y Ca � t+O�a.
C.illAi Vl �..diJ.L
ADDRESSPSj(,Oj•JE3YE�"�I(�XG1' 000"�0h
Clrjy/COMM taI ZIP 92253
'
JOB IS7�3O�E �SPAC___ E . �_ lFernando
�CA
GIlY/COMM,. UNRr/gTtaATjj�,,,jZlLa 92253 .
BOK
PAG
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FIND
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TR1I06765
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215.15
Ccinstructim Fee
MODMA L1i1
SB
TY...;t 18
Wirt
TRACTNAME club
l e'er aQ
OWNER EIi�NAME (L, F. MI) �t �L.
� raticn of &Ufbniia
CONTRACT OR -FIRM NAME
pi
As
O. B= 1000
CITY/COM I A* ZICA 92253
PHONE •
345-2888
LICNC
413636
'
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE •
LICNC 8
USEr �OF ,,TS/F/D W/Attached Garage .
BL
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I ZONFS8
r 41983
Sty 0 La Quflnta
SSB
SSB:
RS@
TFEE
OFC
ZONE ORD 0 •
-
- 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 c;
Date
APPL/PRMTMW
12;434-83
Comb.
Permit to build 1,250
Sq. Ft. of aoazI1
and Garage
Nedbanica7. Fee
$ 26.00
Plan Check Fee
215.15
Ccinstructim Fee
331.00
Electrical Fee
27.50
RU Fee
4.59
Pltmbinq Fee
56.00
Property Dwelopnent Fee �
300.00
Y
_
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r 41983
Sty 0 La Quflnta
TFEE
$ 960.24
BLDG. DEPT. VALUATION $65,840.60
NO.
OPERATION DATE
INSPECTOR
NO
MECHANICAL APPROVALS
Ventilation.System
BUILDING APPROVALS
Plenums & Ducts
1
Set Back
Inlets'& Outlets
33
2
Ftgs & Frms
Appl. Clearance
34
2A
Slab Grade
Smoke Detection Device
35
3
Steel
ADDITIONAL INFORMATION
( SW
36
4
Grout Blocks
37
5
Bond Beams
38
6
Roof Deck
39
7
Framing
3
40
8
Vents
41
9
Garage Fire Wall
42
10
Fireplace P. L.
❑
43
10A
fireplace T.O.
EJ
OP,
11
Exterior Lath
3�
12
Internal Lath
12A
Drywall
13
Finish Grade
INSULATION
Thick R
Val ue
7A
Walls (Batts)
.-, t`
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
JF
ELECTRIC APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring 3 y
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 F inal
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
STREET'NAME
REAR OF PROPERTY LINE
OPERATION
DATE INSPECTOR
MECHANICAL APPROVALS
Ventilation.System
Plenums & Ducts
Furnace Compart.
Inlets'& Outlets
Combustion Air
Compressor
Appl. Clearance
Fire Damper
Smoke Detection Device
Commercial Hood
Final
ADDITIONAL INFORMATION
( SW
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
STREET'NAME
REAR OF PROPERTY LINE