0386 (SATT)LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Divi
and effect.
License Class Lic. Number
Date Contractor
' OWNER -BUILDER DECLARATION: j'hereby affirm that I am exempt from the Contractor's License Law for the
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
•1 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 penally of not more than five hundred dollars ($500.):
O I, as owner of the properly: or my employees with wages as their sole compensation, will do the work, and the
structure is not 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. If, however, the
building or improvemni 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 exculsively contracting with licensed contractors to construct the project (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 contracts for such projects with a contractor(s) licensed pursuant to the
Contractor's License Law.).
❑ 1 am exempt under Sec. B. 8 P.C. (Attached Certificate). ' -
dale 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
❑ Certified copy is hereby furnished.
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. _
. 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.
❑ Certified c py'ts file .with the City Building Inspection DeparCtlooent or Cd Department
Date �,� Applicant/ �
APPLICANT,,.I/�i_Mp(l�.•F��Mmt 0=porat m of California
ADlPi.•S 0.i7l.rif.'x%1000
CITZ'/COM UNI7V/S_TATE ZIP 9 5 '
'°B7 r="j sRiAdUda Fenwxb
CITY/COMMUNITY/STATE/ZIP
a, zlCA 92253
BOX '
PAG
PRC
C
$ 26.00 '
TWN
RNG
SE
S
TRACT 765
lOd
S 41 Fee
6.76
MOD
SB
�t 1'
' _ _a_ -`l�
TRYAaal�C..�TvvjN Club
ennis
jpn
OWNER kiJ (L. F, M1�)
t C3or ation of California.
CONT` RRAAACC OR -FIRM NAME '
ADP, 0, Boat 1000
CITq�'�2 (,X__ NI,T ta,,IICA - 92253 -
PH714�2888
4"636
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC a
TOTAL
FEE
USM ;, T S/F/D W/Atta&led Garage
BL
ZON
FSB
SSB
SSB
RSB
OFC '
' ZONE ORD • -',
LOT SZ
END
SIDE
Date Applicant
NOTICE TO.APPLICANT_ If; aftecmaking this Certificate of 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.'`
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
D 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be'
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or"
demolition dr. dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8, ,
C.A.C.)' y I.
❑ As dwner-builder, 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.
O 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.). • . , 1
Lender's Name
Lender's Address
I 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
III this county to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date '
CERTIFICATE OF COMPLIANCE ANDAUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. Lagree 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 Date
Print Applicant/Agent Name
APPL/PRMT
1 9213 8 M _ ' •
Pian t to buiad 2,078
Sq, Ft, of C�ondominitmt
aiid Garage
Mech�.iical Fee
$ 26.00 '
Plan - Ck Fee '
275,60
CXnzstructi m Fee
424.00
Electrica]. F
33.71
S 41 Fee
6.76
Plt dAM Fee
68,50
Property Delve�lcSumt Flee 450,00
p ynW
u G 4 1983
TOTAL
FEE
$ .1,284.57
VALUATION $96,512.80
BLDG. DEPT.
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 Decka
j .. ��
39 Appl. Clearance
7
Framing
1
7.-//-
40 1 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage Fire Wall
42 Commercial Hood
10
Fireplace P.L.
❑
43 Final
10A
f=ireplace T.O.
❑
OWN
ADDITIONAL INFORMATION
Q/� %0 �✓�R/'7y/�Y
`
� -(C� --g� C.CJ-�-�ua CSV-\
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath ? } K N
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts) ��/c� ,�
12B Ceiling (Batts)
12C Ceiling (Blown)
71-
14 Firial
PLUMBING APPROVALS
15 Ground Plumb -6
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 PROPERTYLINE
PSL P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29. Wiring
29A Grounding Wire ,/Z
29B Bonding
30 Fixtures
31 Service
32. Final