0376 (SATT)1. ..
LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Div'
and effect.
License Class Lic. Number
Date " Contractor•
OWNER -BUILDER DECLARATION: I hereby affirm that I Am exem from'fie 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 sLicenseLaw
(Chapter 9 (commenci ng w ith.section 70D0) of Division 3 oI the Business and Professions Code) or that he is exempt • ..
therefrom and the basis for the alleged exemption. Any violationof Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than.fiv@.hundred dollars ($500.):
❑ I. as owner of.the property, or my employees with wages as their sole compensation, will do the.work, and the
structure is not intended or offered for sale.fSec. 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. It, however, the
building or i mprovemnt 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.).
O 1, 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.).
O 1 am exempt under Sec: B. 8 P.C. (Attached Certificate).
Date 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
0. Certified copy is hereby furnished.
❑ Certit d cop is filed -with the City Building Inspectio§epartmee I rr City t Department.
Date Applicant
PERMIT APPLICATION
City of La Duinta
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 lull force issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
lkiliAM._T�_ �ME�(� _I)�,lt Corp=atgcm of C&Ufoniia
ADDRESS
FU. aACX 1000 .
P.
oI TY/ cO,�r±uNiTYV�/S��TA�TE/Z.
92253
JOB j -SITE 34 7 R�X+c PAX Ferrum o
DI�Tr/C�I.IMUInta,, E/zCA - 92253 '
Box
PAG
PRC�L1
C
Plan Check Fee
TWN
FIND
SE
S
8-165 • 1,
1 LOT
1
Plumbing Fee
5A
58
Unit 3
YAC l..iUb V .
ii�;il"," ' I II mmt Q=p=aticn cif Galifo=da
CObuNTRRAACTOR-FIRM NAME ..
P, U. Bac 1000
CITY/COMMUNITY/STATE/ZIP -
ta Q=ta, CA 92253
35i�=2888
413536
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 11
LICNC
USE OF W/Atm Gaange
BL
ZON
FSB
SSB
SSB
RSB
OFC"
ZONE ORD 0
LOT SZ
END
SIDE
Date Applicant
NOTICE -TO APPLICANT: If, after making 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:,
O l 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 or dismantling thereof; will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, AA 2, Sec341, Title 8,
C.A:C.)
❑ As owner -builder, 'I will.nbt 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 Indusirial�Satety 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
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.
r Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this applicationand 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
Date
APPUPRMT � iLA� �3 C.mb
Pezunt to build 2,187 Sq. Ft.
of C mdwdnitmt
and C>amge
Madbanical Fee
$ 28.50
Plan Check Fee
279.50
ClImstructilon Fee
430.00
Flectrical'Fee
35.08
SNIT Fee
6.90
Plumbing Fee
68.50
Property Development Fee
450.00
ULU
may+ p
l 1983
TOTALFEE
=
$ 1, 298.48
BLDG.DEPT.
S/
VALUATION $98724.20
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUI'LDING.APPROVA•L'S
MECHANICAL APPROVALS
11
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'
02
40
Fire Damper
8
Vents .
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
1.0
Fireplace % P.L.
❑ .
43
Final
10A
Fireplace T.O.
❑
OPON
ADDITIONAL INFORMATION
'�
7-l,oj-8�-•) Cry e.l
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPR- yAL'S
. 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 /7Ll
25 Final
ELECTRIC APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 • F final
Tank Pit 1. L. Line
STREET NAME _
REAR OF PROPERTY LINE