0379 (SATT)PERMIT APPLICATION -7-7- 33-7
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced'wilhin 180 days from date of issuance. OR, it work has been suspended or abandoned for a period of 180 days.
ADP.ss0. Box 1000 .. ._
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
LICENSED CONTRACTORS DECLARATION: 1 hereby affirm'that I am licensed under provisions of Chapter 9 "
the permit is'for one hundred (Sl 00) o, less. I certify that in the performance of the work for which this permit is
' (commencing with Section 7000) of Division 3 o 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 Lic. Number
Date Applicant
Date-^ Contractor
^ r
NOTICE TO APPLICANT: If. after making this Certificate of Exemption• you should become subject to.the Workers'
I
OWNER•BVILDER DECLARATION: 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
be deemed revoked. '
fallowing reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to '
SMI Fee
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 oftheContractor'sLicense 'Law
13 1 hereby certify that no excavation five (5)or more feet in depth into which a person is required to descend, w ill be
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code) pr 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 violatiorI Section 7031.5 by any applicant for a permit ..
demoliton-ordismantling thereof• will be more than thirty-six (36) feet high. (Chap 3.2: Grp 2,'Art 2, Sec341, Titlefl
• subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
C.A.C.)
❑ I. as owner of the properly, or my employees with wages as their sole compensation,will do the work, and the
0 As owrier•builder, I will riot 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 abdve; 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,,.
^
Division IndusVial.Salety Permit No.
through his own employees, provided that such improvements are not intended or offered for sale. If, however. the
of
buildingor improvemnt is sold within one year of completion, the ownerbuilder will 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 agency for 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
SSEI
Contractor's License taw.).
Lender's Address
0 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 .,d
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
WORKERS' COMPENSATION DECLARATION' I hereby affirm that I have a certificate of consent to self -insure or a
of this county to enter upon the above=mentioned property for inspection purposes.
-
certificate of'Workers' Compensation Insurance , or a certified copy thereof (Sec: 3800.'Lab. C.).
Policy No. Company
❑ Certified copy is hereby furnished.
❑ Certifi fl It riffs file w�ilh the City Building Inspection Depa+rI it or City? Department.
Date ,�%�:3 Applicant
a
AP.PL„ Ic},1NTiNAM� E (L F' MI � ClWporatil ofVY.iJJ�Gi
Ca I J fcrn
ADP.ss0. Box 1000 .. ._
CIyY/COMMUNITY/STATE/ZIP_-_,ta_
JOt3,r JTE �E PAC JL C.L aTdo . .
y�y9225yr3
/�°MTY
CI
I
�;ai ZIP _ 92253
Box
PAG
PRC
PRC
C
$ 28:50
TWN
RNG
SE
S
TR1C9765
LOT l
SMI Fee
6.34
MI
SB
Unit 6
NAME
TRT IPs A717 V7'+�
O R ME (L FMI)
ration of Califiornia
CONTRACTOR -FIRM NAME
�e
A°P.�O. Bax 1000
NI,,,, ZICA 92253 '
CIT,FY/�OMMU, _,nta
PHONE '
345-2888
LICNC Y
413636
'
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC M
USE OF PERMIT
C cnd, S/F/D W/Attached Garage
BL
ZON
FSB
SSB
SSEI
RSB
OFC
ZONE ORD 0
LOT SZ
END
SIDE
' Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE ANO 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 bufdling
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
APPL/PRMT 7q
11-Ti3-83 _ cmb
Penaiitto build 2,083
Sq. Ft. of Ooh
and Garage
Mechanical Fee
$ 28:50
Plan Check Fee.
263.90
f0mistructialn Fes
406.00
Electrical Fee'
33.78
SMI Fee
6.34
Plumbing Fee
68„00
Pziloperty DemlCpmnt Fee 450.00
I
l% E
I -N Aft
(�paqU L L 141983
,A City rar( F rn1., r .n
TFEE
$ 1,256.52
BLDG. DEPT.
r
VALUATION $90,705.80
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 Deck
39 Appl..Clearance
7
Framing
/,L'l
40 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.
❑
NON ADDITIONAL INFORMATION'
� G",N
P 51N
SEWAGE SYSTEM SIZE .& LOCATION
11 Exterior Lath'/�%/o2gej�
12 Internal Lath
4z 4
12A Drywall
13 Finish Grade-�C.('-gL-I
INSULATION Thick Vaall ue
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 7
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
p/L P/I
STREET NAME
• 26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire - —g
29B Bonding
30 Fixtures
31 Service
32 Final