0282 (SATT)t
^ PERMIT APPLICATION
City of La Duinta I G 1! 1
y-
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.
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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; I shall not employ any, person in any manner so asto become subject to the Workers'CompensationLaws of.,
and effect.
California.
License Class Lic. Number
Date Applicant. '
Date Contractor
NOTICE TO APPLICANT: ;It, after making this Certificate of,Exemption, you should become subjectto the Workers' -
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt iromdhe C6itractor'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 deelned:re oked. T v
_ construct, alter, improve, demolish, or repair.any structure, prior to its issuance, also requires the.applicantfor
DIVISION OF INDUSTRIAL SAFETY. PERMIT CERTIFICATION: - • ' . .
• such permittofile asigned statementthat heislicensed pursuanttothe.provisionsofthe Contractor'sLicense Law r
p:'Ihereby certify that noexcavation five (5)ormore feet indepth into which a' person isrequired todescend, will be
(Chapter.9(commencing with section 7000) of Division 3 of the Business and Professions Code) orthat he is exempt"•.:
" -made in,connectioo with work authorized by Ifiis 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 applicantfora-permit'., _
demolition or dismantling thereof, will be. more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2 Sec 341, Title B.. =
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): -
CAC)
I. as owner of the.property, or my employeeswith wages as their sole coMpensation, will do the work; and the
❑ As' owner,builder, I'will'not.employ anyone to do work which wouldrregoire 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- :•.
- -. . - . x . .
-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 or improvemnt is sold within one year.of completion, the owner -builder will have the burden of proving that _
Date Applicant
he did not buildor improve for the purpose of sale.). .. - • , Y. u CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a�constructIon lending agency for the performance''".
❑ I, as owner of, the property, am excursively contract ing,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 notapply to an owner of property who
Lender's'Name
builds or improves thereon, and who'contracts for.such projects with a contractor(s) licensed pursuant to the -
OFC..'
Contractor's License Law.).
Lender's Address
O I am exempt under Sec.- . B. & P.C. (Attached Certificate). -
,.: I.iertify that I have read this application and state that the above information is correct. I agree to comply with all. ,
Date Owner c
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
END
of this county to enter upon the above-mentioned property for inspection -purposes:
WORKERS' COMPENSATION DECLARATION: I hereby affirm that'I have a certificate of consent to self -insure, ora
certificate of Workers' Compensation Insurance , or a certified copy thereof (Secr3800. L&,C.).--P,: ••
_' Signature of Applicant or Agent ' Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that.
❑ Certified copy is hereby furnished:
the information given is correct. I agree to comply with all state•laws and county ordinances relating to buidling
❑ Certified copy is filed with the City Building Inspection Department or City1 -Department.
construction, and authorize a' representative of the City of La Ouinta Department of Building and Safety to enter
upon the propi:rty for which I have applied for this permit for the purpose of making inspections..,
�r: • ��
Date Applicant
J j y
wff�,
Signature of Applicant or Agent r Date -
•C/J
—
Print Applicant/Agent Name
AP.PVLiCT?IAME(I) ' t (�y.yy�' -
ratkin
��.
...
ADko•SSO• BOX 100.0
CITVldOMMU�IITY/SwTA1T/ZIPCA 92253
=I
JOY&C AD ESSLSP,ACi-T�0,wrtie - -
�U•,M(,
CITY/COMNITY�iS/�G#Z`'M1Ch 92253 -
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PAG
PRG
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341.58
TWN
RNG
SE.
S
TR2876i
LOT
' 73.00
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MOD
SB
TRACT NAME
OWNER NAM&:IL RI:11� O=p=tion*-. .. ,.
CONTRA�,&R:-FIFIRM NAME '-
ADF.ESSO. B aC 1000 .. .
CITYy -(COMM �S E/ZIP 92253 .
PHONE 0
9%13636
:..• .; .. TOTAL
FEE
ARC/ENG FIRM NAME ,
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONE 11
LICNC 0
-
USE OPERMIT
W -0j,
TWdj,w E, _c i IPlumbing, Bldg* dg* s .
BL
ZON
FSB
• SSB
'SSB
RSB
OFC..'
ZONE ORD w: " -
"LOT SZ
-
c
END
. SIDE
APP�VPYRmMT� y, y,� f . / il' / • O;AT�J-83
Peanut {J1 J ll o�!</JI 'J..,
bUM S • Ft, Jof
Ow4adniuin 3GS7
Mechanical Fee
19.00
Plan 1� Fee
341.58
Utwtxvictim Fee
525.50
Eleci-si,ca7. Fee 49,02
SMS Fee "
91.56
Plizmbixig Fee -
' 73.00
Property Devellopvnt Fee
600.00
V �
,
,6
:..• .; .. TOTAL
FEE
$1,,61.7,66
,v VALUATION 1 $136.,386.90
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
/i /,Q 3
,/
35
1 Furnace Compart.
3
Steel
/C7
1714-
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
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O.
❑
OP'NO. ADDITIONAL INFORMATION
O ,�
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'
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
r
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL
STREET NAME
P)
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final