0283 (SATT)PERMIT APPLICATION
Y 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.
_ n CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if .
LICENSED CONTRACTORS -DECLARATION: I hereby affirm Ihat' I' am licensed under provisions of Chapter 9 the permit is for one hundred ($100) It, less. I certify that 'in the performance of the work for which this permit is
(commencing with Section 7000)•of Division 3of the Business and Professions Code, -and my license is infull force issued, I shall not employ any person inany mannerso asto become subject tothe Workers'CompensationLaws of
and effect. - California.
License Class Lic. Number Date Applicant
r
Date Contractor - . •• NOTICE TO APPLICANT: If,-after.making this Certificate of Exemption, you should become subject -to Ihe•Workers'
OWNER -BUILDER DECLA
+:RATION: 'I'hereby affirm that I am exempt'from the Conractor's License Law for the Compensation provisions of the Labor Code„you must forthwith comply with such provisions or this'permit shall
t - be deemed revoked '
following reason (Sec. 7031.5; Business and Professions Code: Any -city or county which req.uires a permit to .y
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 asigned statement that heislicensedpursuant tothe provisions ofthe _Contra ctor'sLicense Law' ❑ Iliereby'certifythatnoexcavation five (5)ormore feet indepth intowhich apersonisrequired todescend, witIbe
.(Chapter,9(commencing with section 7000) of Division3 of the Business and ProfessionsCode) orthat 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 ,v demolition or dismantling.thereo . will be more'thanthirty-six (36) feet high>(Chap 3.2, Grp 2?An'2; Sec341; Title8;
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): C.A.C.)
a I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the Lu O -As owner%bUilder;i'wilPnot 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 Contractors License Industrial Safety, as noted' above, unle.ss'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 worl(himself or . r
through his own employees, provided that such improvements are not.intended or -offered for sale. If, however, the ' ; O. Division. of Industrial Safety Permit No.
building orimprovemntissoldwilhinone 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
O 1, 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 ownerof'property who Lender's Name
builds or improves thereon, and who contracts for such projects with a contractors) licensed'pursuant to the
Contractor's License Law.). Lender's Address
01 am exempt under Sec. . B. 8 P.C..(Altached 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, -
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that l have a certificate of consent to self -insure: ora
'certificate of Workers' Compensation Insurance , or a'certified copy thereof (Sec. 3800. Lab. C.).' • ' ' Signature of A'pplicant or Agent Date
Policy No. Company ._
- .•. .. ' CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify) have read this application and state lhat r:', '
O Certified copy is hereby furnished: the information given is•'correct. I agree to comply with all state laws and county ordinances relating to buidling s
O Certified copy isfiled with the City. Building Inspection Department or City - Department. construction, and authorize a;representative of the -City of. La Ouinta Department of Building and Safety to enter
upon the property for,whicIt I have applied for this permit. for the purpose of making inspections.
Date ApplicantXa ' r .. -
"!�. Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPC�A•'NTtNAME (. .,,14F-. D t ^j�y.nj�y.�i'.1...�'
LLJ�CC''V1C; .i.V rwr+.jnw+.cAt..LV1S �•'
ADO.ESS' Box 1000 .
CIvt,.O JJGLMMJ _uN�Tr/S do =I 92253
�,;(•�
JOB SITELAD4�RESSS/SPAG
x rto M Nio to
CIM( UNIT_r/s aJE' lfyw 92253 �• .. .
�,
BON
PAG .�
PRC
C
341.58. '
TWN.
PING.
SE ..
S
TR1076?
LOT
Plumtaing Fee
6,
MOD
SB
�•:.
TRACT NAME
MEW M
O �H�NAVme., y
- TraM6•
COSY R -FIRM NAME • • '.
ADDRESS 1'. 0, Bc= 1000
C17�r/COMMr yyNlm/$ra,./Zh 92253
o"S445-2888
613636
$1,617.66
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC 0
t,sE, OF I - ��, Plunb B
BL
ZON
FSB
SSB
Sse
RSB
.OFC
ZONE ORD N
- LOT SZ
:END
- SIDE
APPVPRMTCsDATE
Pe r I t `to Wild 657 Sq. Ft. of
Ccffb• +
Pnicai Fee
19.00
Plan Check Fee ..,
341.58. '
Cmistxwct ion Fee
525.50
E%c.-trical Fm
49.02
SMI Fee
• 9.56
Plumtaing Fee
73.00
Ply Dev%rient -Fee
600.00
RECEI V
'.
UG 161983
eity -of inta
t..' .' TTLFEE
$1,617.66
BLDG. DEPT.
VALUATION $136,386.90.
- -
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
��/O 173
/off •
35
Furnace Compart.
3
Steel.
/cJ ,?
C/•
36
1 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
10
Fireplace P.L.
❑
43
Final
10A
fireplace T.O.
❑
OP'N
NO.
ADDITIONAL INFORMATION
;
/
I b
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath g
�/ii?�
12A ..Drywall � ,� �7 —jy•
13 Finish Grade
INSULATION Thick R"
Value
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 7,21,
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test IlJylffV. 77W
25 Final
Tank Pit L. Line-
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL PA
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final