0388 (SATT)LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) ol.Divi
and effect.
License Class Lic: Number
Date Contractor
OWNER -BUILDER DECLARATION: "I hereby affirm that I -am exempt`from the Contractor's License Law for.tlie•
.following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (commencing with section,7000) of Division 3 of the. Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (S500.):
O I. as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the ,
structure isnot intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
through his own employees, provided that such improvements are not intended or offered for sale. lf, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that .
he did not build or improve for the purpose of sale.).
0 I, as owner of the property am excuIsivel y contracting with licensed contractors to construct the project4Sec.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).,
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby 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. :•
O Certified cap is lite/ywith the City Building Inspecfiori,�De/p7�/rtme 1 or-Cit1.� s Department.
Date �� Applicant c ✓ A ��
PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
??-51f I.
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. '
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE:' This section need not be completed if
ON:`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
sion 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
California.
APP it JWv(>L MI) t ((''��..��rr��rr tilde of CaUfmda
ADD.IiESSO. B= 1000 . - ..
CIT aVt,/COMM COMMUNITY/STATE/ZIP 92253
JDji�i�=. 23 ADDRESS/SPACE Fen umdo .
CITY/COMMUNITY/STATE/ZIP,_yi�.0 92653 .
BOK
PAG
PRC
C
Plan Me& Fee
TWN-
PING
SE
S
TRJU 765
LOT 1
7.60
Pliu�ing Fee
MOE
SB
Unit 15
W�.L
TRACTNAME.
Club Vti 11 s
OWNER L F, MI�MI� �at.i�All of C aUfo iia
CONTRACTOR -FIRM NAME.
ADDRESS O. Boas 1000
CITY/COMMUNITY/STATE/ZIP
NIJY/ta,, ICA 92253 -
PHONE k�2888
43t�3fi
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N
$ 1„346.Y9
LICNC 0
,
"SilP,ki, T S/F/D W/Attached Ce
SL
ZON
FSB
SSB
SSB
RSB
OFC '
ZONE ORD N
LOT SZ,
- END
'SIDE
Date Applicant -
NOTICE TO APPLICANT: IL after making this Certificateof Exemption, you should become subject to the Workers, .
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit.shall
be deemed revoked. L.
DIVISION OF, INDUSTRIAL SAFETY PERMIT.CERTIFICATION:
O l hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend; w ill be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
'demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title8,
C.A.C.) •
O As owner -budder. I will not employ anyone to do work which would require -a permit from the Division of
Industrial Safety, as noted -above, unless such person has a.permit to do such work from that division.
v 0 Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
1 -certify -that I have read this application and state that the above information is correct. I agree to comply with all
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 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:l, have applied for this permit for the purpose of making inspections..
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPUPRMT „ � 12OU-1— 9-3
�• -
Peaait to build 2,382 Sq. Ft. of CX�zium
and Garage
Mechanical Fee
$ 28.50
Plan Me& Fee
296.08
Oonstr uctian Fee
455.50
Fee .
37.51
SMI Fee
7.60
Pliu�ing Fee
71.00
PYbpwW Dwela�t Fee
450.00
Wc(�
• TOTAL
$ 1„346.Y9
BLDG. DEPT.
y
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.Aeck
39 Appl. Clearance
7
Framing
3 t
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage Fire Wall '
42 Commercial. Hood
10
Fireplace P. L.
❑
43 Final
t0A
Fireplace T.O.
.❑
NON ADDITIONAL INFORMATION
/17/ 07
ry (� Li "'— — U� (`
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its S1✓
1�
,
SEWAGE SYSTEM SIZE & LOCATION I
11 Exterior Lath
12..Internal Lath
12A Drywall t
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/L
P/I
26 Power Pole
27 Conduit "
28 Service Entrance
29 Wiring.
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME