0383 (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.
•
044..
-+- 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, less. I 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.
California -
License Class Lic..Number
Date Applicant
- Date Contractor
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 a signed.statement that he is licensed pursuant to the provisions oftheContra , clor'sLicense Law
b I 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) 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 yiolation 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.):
C.A.C.) '• I .
0 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
Indusfrial'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, avid who does such work himself or
r
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
0 Division of Industrial Safety Permit No.
building orimproverrntissold 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.). "
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7d P I C d Th Contractor's License Law does not a I to an owner of ropert who
of the work for which this permit is issued (Sec. 3097: Civ. C.).
usiness an ro essions o e. e PD Y D Y
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 v'
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.). r.
Policy No. Company
. 0 Certified copy is hereby furnished.
❑ Certifiedscop s itiled Cit/h the City Building Inspection,.Dryepartment or City Department. '
Date �f i Applicant
APpIC T NAM (L. F MI__)��_t ,may. 6fG 1 � fan t,�
1 \.QiiL�AR1LLG
"Y��d. � 1000
Cllr/cuNlTv/s�.TAarE/ZIPS 92253
JO71.�5/•�.'S.�I1LELy P"`9%Er'T�� F
°IGMM°NITrj/ZIPS 92253
BOK
PAG
PRC
C
Piaci Fee
TWN
RNG
SE .
S
TRACT 765
LOT 1
4.59
Plumbing Fee
MOD
C1
SB
t 10
Unit
TR�CIIAM � Club Villas.
OWNER NAMW FW MI)-
t ' Corporation of Cal ifomia
CONT-RAC�JOR-FIRM NAME
ADDRESS
0, B= 1000
CITU/CO ,A �ta, ZA 92253
P"345•-2888
r utC 14 1
`413636
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC #
' -
usb ;ITS/F/D W/AttacW Osage
BL
ZON
FSB
SSB
sse
RSB
OFC
ZONE ORD •
LOT SZ
- END
SIDE
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
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 I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent
r Print Applicant/Agent Name
Date
APPL/PRMT 12/.3/83
Cm1b.
Pewit to build 1,250 Sq. Ft. of Cor�danini�an
and Girdge. .
Mechanica�.l. Fee
$ 26.00
Piaci Fee
215.15
Construction Fee
331.00
Electrical Fee
27.50
SM Fee
4.59
Plumbing Fee
56.00
Property Developnmt Fee
300.00
r utC 14 1
6
TOTAL
FEE
$ 960.244,
VALUATIONI$ 65,840.60-
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
351.
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
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
CommercialHood
10
Fireplace P.L.
❑
43
Final
10A
Fireplace T.O.
❑
OWN
ADDITIONAL INFORMATION
�.t9-g�C.CW�� Crv\
V".'Q
P
_SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath 3
12 Internal LathVv�Q/C/
12A Drywall
13 Finish Grade
INSULATIONThick
Lal
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
'
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire -,�-gj
29B Bonding
30 Fixtures
31 Service
32 Final