0552 (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.
' •a r, '
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it .-
LICENSED CONTRACTORS DECLARATION: I hereby. aflirm 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 the Workers' Compensation Laws of. ,
and effect.
California.
License Class Lic..Number
Date "Applicant.
•
Date ContractorNOTICE
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 Cod_ e, you must forthwith comply.with such provisions or this permit shall
•' "
tollowing 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:
suchpermillofile.asignedstatementthatheislicensed.pursuant!otheprovisionsoftheContractor'sLicenseLaw
01 hereby certify that no excavation five (5) or more feet in depth into which a 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, ano.that no building structure; scaffolding; falsework, or
'therefrom and the basis•jor the alleged exemption; Anyyiolation of -Section 7031.5 by applicant for a per
demolition or dismantling thereof; will be more than thirty-six (36)4eet high. (Chap 3.2, Grp 2, Art 2; Sec 341, Title 8, -
subjects the applicant to a civil penalty of not more than five hundred dollars ($500•):
C.A'.C.)
1, 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
- , ' r.
through his own employees, provided that such improvements are not intended or -offered for sale. ll, however; the
O. Division of Industrial Safety Pprrmit No.
building or improvemni is sold within oneyear of.completion, the owner -builder will havethe burden of proving that
Date Applicant
he did not build.or. improve for the purpose of sale.).
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-CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency forthe performance
O I, as owner of the property, am exculsivelycontracting.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 , • -
Lender's Name' "
'builds or improves thereon, and who contracts: for such projects with -a contractor(s) licensed pursuant. to the
Contractor's License Law.)..
Lender's Address
❑ I am.exemptunder Sec: B. 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 Owner'
city and county ordinances and state laws relating to build ingiconstruction, and hereby authorize representatives .
-for
of this county to enter upon the above-mentioned property inspection, purposes. .
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.).
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:Icertify'Ihave read this application and state that ,
r O Certified copy is hereby furnished. Y
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
•O Certified copy is filed with the City Building Inspection Department or City • M Department..
construction, and authorize a'representative of the City of La Ouinta Department of Building and. Safety. to -enter.,
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upon the property for which I ha4applied for this permit for the purpose of making inspections. -
Date Applicant - ••--ry L-
Signature of Applicant or Agent Date
APPLICANT NAME'(L, F MI) -
t+l, t5. v�r�lCi5c5�1 "
A4OU N. Tustin Avenue, Suite 231
CITU/CO MUNITY_- /STAeE/21Q_ 92705
.101346 ADDRESS/SPACE
.b -Iat
CITY/COMMUNITY/STATE/ZIP -
La t=ta, c� 92253
BOK
PAG
PRC .
C
Paid
TWN .:.
RNG
SE
S
TLA3640-3
2.y
Plumbing Fee
61.00
8
SB
...
TRACT NAME
11agum De La Paz, Ltd.
OWNS ER NAM� F. MI tpa - -
CONTRACTOR -FIRM NAME
AOORESS,
CITY/COMMUNITY/STATE/ZIP -
PHONE 4) 558-+3766`
LIDNC .
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP -
PHONE M
LICNC •USE
,
OF
SAIDPERIT(Oox�damiWinj
BL
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FSB
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SSB
RSB
OFC, .
ZONE ORD ..
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END.
. SIDE _
Print Applicant/Agent Name
44"
cbndo
Plan t to oonstz`wc't 11894 Sq. Ft, of S/F/D
with 400 Sq. Ft. of Garage Per A mr+ d PianE
Nei al -u i :al Fee
Plan Check Fee '
Paid
CXmstuc$;fon Fie
445.50
electrical Fee.
34.67'
SMI Fee
7932 '
Plumbing Fee
61.00
Property Dmelorinebt Fee
450.00
REC'LIE0
. TOTAL
FEE
$1016.49
BLDG. DEPT. VALUATIONI$ 104,664.40
A&
NO.
OPERATION ATE
INSPECTOR
NO.
O ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
1 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
42
Commercial Hood
10
Fireplace P.L.
❑ \
43
Final
10A
fireplace T.O.
❑
OWN
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 / —c —y�f �G
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage.Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final '!S-�?' 9• C•.
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
.
P/L P/I
STREET NAME
26 Power Pole
27 Conduit •
28 Service Entrance
29 Wiring . •
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final