0378 (SATT)i LICENSED CONTRACTORS DECLARATI
(commencing with Section 7000) of Divi
and effect.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that'! 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 h e 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.):
0 I. as owner of the property, or my employees with wages asaheir 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 safe: lf;however, the
building or improvemnt its 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.).
0 1 am exempt under Sec. :.B.,& 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
O Certified copy is hereby furnished. - ,
n
0 CerbI1 0 op is filed w'th the City Building Inspection,De0-4 1 inttorrCCiitfy Department.
Date !2� Applicant.
PERMIT APPLICATION w $ Y3
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: t hereby, affirm that I•am .licensed under provisions of Chapter 9 .the permit is for one hundred ($100) o. less. I certify that in the performance of the work for which this permit is
Sion 3 of the Business and Professions Code, and my license is in full force issued. I shall not employ any person in any mannerso as to become subject to the Workers' Compensation Laws of
California.
APPLICANT T1 EVGl M!� �zatim & �.G3 forma
ADDRESS' &W 1000
CIT�y/COMMU,, ,, N6TV/$�TA�T,ZICA 92253
aojs 7-3,43 sHWPAc`i��3CElYC�A FP•Zi}3 xb
CITY/C° ta. ZI�A 92253
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BOK
PRC
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TRIC
LOT l
6,34
Plumbing Fee
M_OD
SO
t
TRACT NAME
Club Villas
Y
OWNER NAME_(L FWJ
t WrWrat�Z of Wifon
CONTRACTOR -FIRM NAME
ADDRESSP®. Bak 1000
CIT11'/COr�tuNiTY/ TA s/ZIPS 92253 .
LL3C4-1-288j8�j8 t [J4
PHONE
3636
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE •
LICNC N
usE of PE�tMIT
S/F/D W/Attached Garage
BL
ZON
FSB
SSB
SSB
.RSB
ZONE ORD ' ;
LOT SZ
END
SIO.
Date Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions ol,the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked. "
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
'0 I hereby certify that no excavation five(5) or more f eet 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 mole than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2: Sec341. Title B.
C.A.C.) . . . ,q-14:
O As owner -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.
.0 Division of Industrial Safety Permit No.
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agencyfor the performance
Y of the work for which this permit is issued (Sec. 3097, Giv. C.).
Lender's Name
Lender's Address
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
Print Applicant/Agent Name
Date
APPUPRMT I� Q 12_Ea �3
amb
Permit to build 2,083 Sq. Ft. of ni�n
and (rage
Mechanic—al cal Fee
$ 28.50
Plan Check Fee
263.90
C nstructian Fee
406,00
Electrical. Fee
:33,78
SMI Fee
6,34
Plumbing Fee
68.00
Property Development Fee
450.00
ULU
ka 1J LJ] CRY el
a Quints
TOTAL
FEE
$
1.256.52,
BLDG. DEPT.
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
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.
❑
OPO'N ADDITIONAL INFORMATION
— `q- 8 C,01 �^��1 U� `"C.1/V�-o.X ✓�Cx/`
PSY\/
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick "R"
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb 6
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
26 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
29B Bonding
30 Fixtures
31 Service
32 F inal