0222 (SATT)- PERMIT APPLICATION -" • (�
City of La Duinta
Department of Building
and Saft
ty
This permit becomes void if work not commenced within 180 days from date of
issuance, 0N_
ark has been suspended or abandoned for a period of 180 days.
PRC
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 lull force'
issued. Mhall not employ any person in any manner so as to become subject lathe Workers'CompensationLaws of
and effect.
California.
License Class Lic. Number
Date Applicant
Date Contractor
NOTICE TO APPLICANT: 11. after making this Certificate o1 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 foi
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement thathe is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no excavation five (5) or more feet in depth into whicha 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 violation 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, Sec341, TitleB,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
CAC) ,
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
Industrial 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, and who does such work himself or
BL
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 orimprovemntissold within one yearofcompletion, the owner -builder will havethe burden of provingthat
Date Applicant
he did not build or improve for the purpose of sale:).
SSB
0 I, as owner of the property. am exculsively contracting with licensed contractors to construct the project (Sec.
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.).
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
Lender's Name
Qontractor's License Law.).
Lender's Address
0 1 am exempt under Sec. B. & 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
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
WORKERS' COMP NSATt R
of this county to enter upon the above-mentioned property for inspection purposes.
E ON DECLA ATION. I hereby alfum that I have a certlflcate 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.
O Certified co y is filed with the City Building Inspection Dep rtmeni«City Department.
Date {�VA �� Applicant � n 1 % r✓
APPLICANT NAME (L, F. MI)
. Develoamt Corporation
ADDRESS0 i000
CITY/COMMUNITY/STATE/ZIP r •-
Za Qia:Uita, CA, 92253
JOB SITE1�G ADD ECYrifi {re• ,
CITY/COMMUNITY/STATE/ZIP
La ¢ulnta, CA 92253
BOK
PAG
PRC
I C
C msta uctim Fie
TWN
RNG
SE
'S
TR�767
LOT
63.00 ,• .:
P iety Deveiopmmnt Fee
MOD
SB
TRACT NAME
OWNER NAME (L. F, MI) .
, in�DevvelA atim -
CONTRACTOR -FIRM NAME
Same
ADDRESS
P. :0. Bw 1000
CITY/COMMUNLTY/STATE/ZIP
Ya • Q.uzata, CA 98253 .
PHONE NLICNC
345-2888
41
N
41.3G3�i
'
ARC/ENG FIRM NAME - - - -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC N
v"
US OF P,ER:ITtl • r PltmbiMr B1dg. - -
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ
'END
SIDE
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 Duinta Department of Building and Safety to enter
upon the property for which l have applied for this permit for the purpose of making inspections..
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
i 8e15-83 Ccnb.
APPVPRMTgR 2'969
PE iCtG
3t do $ �9G9 -.Ft. Of
2C�1xi1a3 11 Fee S
19.00
Plan Check Fme
291..20 j . -
C msta uctim Fie
448.00 - -
Elactri=l Feta
40,71
SMI Fee \ .
7.39,
Plumbing Fee
63.00 ,• .:
P iety Deveiopmmnt Fee
450.08
IR r-
C71ty of.—La Qum
41
r TOTAL
FEE
$1,319i.30
VALUATION ,
044.70
Arrow Printing 250/1$3 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg Dept.
NO.
OPERATION DATE
OPERATION I DATE INSPECTOR
BUILDING APPROVALS
1
Set Back
33
2
Ftgs & Frms
34
2A
Slab Grade
35
3
Steel
" s
4
Grout Blocks
37
5
Bond Beams
38
6
Roof Deck
39
7
Framing
40
8
Vents
41
9
Garage Fire Wall
42
10
Fireplace P. L.
❑
10A
fireplace T.O.
❑
11
Exterior Lath
3
12'
Internal Lath
12A
Drywall
13
Finish Grade
IF
INSULATION
Thick R
Value
7A
Walls (Batts)
12B
Ceiling (Batts)
j
12C
Ceiling (Blown)
14
Final
PLUMBING APPROVALS
INSPECTOR
NO.
OPERATION I DATE INSPECTOR
MECHANICAL APPROVALS
33
Ventilation System
34
Plenums & Ducts
35
Furnace Compart.
�•/�i
36
Inlets & Outlets
37
Combustion Air
38
Compressor
39
Appl. Clearance
40
Fire Damper
41
Smoke Detection Device
42
Commercial Hood
43
Final
OPEN ADDITIONAL INFORMATION
NO.
1-2
d dZ
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 - Sewer Q y
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
ELECTRIC APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire P
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
REAR OF PROPERTY LINE