0555 (SFD)PERMIT APPLICATION
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
LICENSEDCONTRACTORS 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 full force -issued, I shall not employ any person in any manner so as to become subject to lie Workers'Compensation Laws of
and effect. California.
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I 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 he is licensed pursuant to the provisions of the Contra ctor'sLicense 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 ($500.):
.O I, as owner of the property, or my employees•with wages as their 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 sale. If, however, the
building or i mprovemnt is sold within one year of completion, the owner -builder wi,I I have the burden of proving that
he did not build or.improve for the purpose of sale.).
❑ 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.).
❑ 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
bate 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.
O Certified copy is filed with thkily Building Inspection Department or City Department.
Date Applicant - -
APPLICANT NAME (L, F, MI) '
me s.
ADDRESS
400 N.. Tustdn Avemue,. Suite 231
CITY/COMMUNITY/STATE/ZIP '
Santa Ata, CA 92705
JOB CE
i- It DCane DRESSISPAScxanas
CITY/COMMUNITY/STATE/ZIP
La Quanta, CA 92253
BOK
PAG
PRC
C
Plurbing 61.00
TWIN
RNG
SE
S'
TRACT
136140-3
I LOT
29
s
1
MOD
1 2A
SB
'
TRACT NAME '
Ia=ia De La Paz, Ltd
OWNER NAME (L. F. MI)
Sam as ahJL. e
CONTRACTOR -FIRM NAME .. ^
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N
(714) 558-3766
LICNC 0
-
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC •
-
USE OF ►y�L'��YY IT(�K�.iww+a�a�
BL
ZON
FSB
SSB
SSB
RSB
OFC•
'
' ZONE ORD N
LOT SZ
END
SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the'Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or.this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 1 hereby certify that no excavation five (5) or more feet 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 more than thirty-six (38) feet high. (Chap 3.2, Grp 2, Art 2. Sec 341, Title B,
C.A.C.)
0 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.
O Division of Industrial. Safety Permit No. _
Date Applicant
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: 0.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information iscorrect.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 courtly 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 Date
Print Applicant/Agent Name
APPL/PRMT �' 11DAZTE CMdo
P YdR
Pe mit to =isstzuct. 1,894 1-3, Ft, of S/F/D
with 400 Sq, Ft, of Garac Per Appr<wed Plms
meehardCal Fee $ 18.00
Plan Ctxdc Fee Paid
Const n=ticn Fee 445.50
aectrinal. Fee 34,67
STEP Fee 7,32
Plurbing 61.00
Pr.gxr y Elimmlarr.wit Fee 450900
n
F BE (.
City Cf U: QuinLz
s
TOTAL
FEE
$ 1,016.49
BLDG. DEPT. VALUATION 1 $104,664.40.
Ah
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
j - / -moi
G
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
X C,
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final �l -
10A
Fireplace T.O. ❑
NO.
ADDITIONAL INFORMATION
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 / I " / —?(f
16 Water Piping Cb
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring •
29A Grounding Wire / /- / - �' / (�
29B Bonding
30 Fixtures
31 Service
32 Final