0221 (SATT)r r
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 F •,
PAG
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 Sof 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 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
❑ 1hereby certify that noexcavation five (5)ormore feet indepthintowhich aperson isrequired todescend,willbe
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
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, Art 2, Sec341, Title8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):.
C.A.C.)
O I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
❑ As owner -builder, 1 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
Law does not apply to an owner of property who builds, or improves thereon, add who does such work himself or
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
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 or improverrint is sold within one year of completion, 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
❑ 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
builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the
Lender's Name
Contractor's License Law.).
Lender's Address
❑ 1 am exempt under Sec. 8. 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 V Owner -
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, ora
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.).
ZONE ORD N
Policy No. Company
Signature of Applicant or Agent Date
• Certified copy is hereby furnished.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
END
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
O Certified cop is filed with the City Building Inspection`dDepartmentitr City Department.
Date -7 Applicant 1 " ) r/
construction, and authorize a representative of the City of La Duinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections.
r °
Signature of Applicant or Agent Date
4rnL
Print Applicant/Agent Name
APPLICANTndaF�•MI. ) _ Coup w
1 iK�1d y�+X�•�":X
ADDRESS
}RESS B= 1000
CITY/COMMUNITY/STATE/ZIP
La 0116ta, CA 92253
JOB SITE ADDRESS/SPACE y
162 Calle Norte
CITY/COMMUNITY/STATE/ZIP -
A Quinta, CA 92253
BOK
PAG
PRC
C
coratracticin nee 448.00. ^
TWN
RNG
SE
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TRACT
111767
LOT
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MOD
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(i/(/AJ /
TRACT NAME
OWNEyq - AIME (L. F, MI) {.1�
O=P=at im
CONT_ RACTOR,FIRM NAME
AODRESS
F. 0. BCC 1080
CITY/COMMUNITY/STATE/ZIP
la eta, CA 92253
PHONE N
38-2888
LICNC
4x3636
I
ARC/ENG FIRM NAME
ADDRESS - -
i t .
CITY/COMMUNITY/STATE/ZIP -
PHONE N
LICNC N
'
USEx+O•PERMIT Elec... Plumbing, Bldg.
SL
ZON
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I SSB I
SSB
RSB
OFC,_
ZONE ORD N
LOT SZ
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END
SIDE" ,
APP��UP,,R,,,,M,�T,,,,�� }';Zyy,,,,,��� yy,� 1
Ci7.L ai t to iJ1,Jl.i ld- 2r969 w l: t o,
�%
�.QA6.AJLili.� ium
deal Fee
19.00
A= Fee 291.20
coratracticin nee 448.00. ^
Mectriml Fee
40,71,
S[ Fee -7.39-
•7.39 -
Plumbing
Plumb ng Fee
63,00 _
Pxoperty Dmmlqpent Fbe 450:00
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■ ` E:
AUG 16
ritv of La buinta
t
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TOTAL
` FEE
4IF319 3u
- - � , �,. .• � : •n i r • ' �� � - 7 , n F•d'
1 ; - VALUATION ,5105,044;70
Arrow Printing 250/1-83 White: Finance ,Canary: Assessor Pink: Applicant Tag:;Bldg. Dept.. ""•
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
3
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O.
❑
OP'NO.
ADDITIONAL INFORMATION
Z// �
/
JUS C%%%
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick
Value
7A Walls (Batts)
126 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 �Q 3
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
STREET NAME
P/I
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
Igo