0550 (SFD)PERMIT APPLICATION
City of La Duinta
• Department of Building and Safety •,
This permit becomes void if work not commenced within 1BO'days from date of issuance; OR, if work' has been suspended or abandoned for a period of 180 days
• I I . .. • -
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 30l the Business and Professions Code, and my license is in lull force
issued, I shall not employ any person many mannersoasto become subject tothe Workers'Compensation Laws of
and effect.
California.
License Class Lir,. 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 fo_(thwith-compty with such provisions or this permit shall
be deemed revoked.
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
DIVISION OF. INDUSTRIAL. SAFETY, PERMIT CERTIFICATION: -
such permit tofileasignedstatement that he -is licensed pursuant totheprovisionsoftheContractorsLicense Law 4.0
1 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, 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 permit ..
demolition or dismantling thereof, will be moro.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.): -
C.A:C.)'
❑ L.as owner of the property, or my employees with wages as their sole compensation, will do the work, and the❑
As owner -builder; Iwill not employ anyone to do work.which would require a permit from the Division of
y' 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.divisions
Law does not apply to an owner of property who builds. or improves thereon, acid who does such work himself.or
ADDRESS
through his own employees, provided that such improvements are not intended or offered for sale. It; however, the
O Division of Industrial Salety.Permit No.
building orimprovemntissoldwithinone 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: Thereby affirm that there is a construction lending agency for the performance
❑.l, 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. 3091,.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 ,
SSB
Contractor's License Law.).
Lender's Address
-O 1 am exempt' under. Sec. . B. B P.C. (Attached Certificate). ,.
I certify that 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 I have a certificate of consent to self -insure, -ora
.. -
` 'certiticate'of Vorkers' Compensation Insurance , or a certified copy thereof (Sec: 3800;Lab. C.).. -t,
Signature of Applicant or Agent Date"
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify) have read thisapplication and state that '• '
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
R.` O Certified copy is filed with`the City Building Inspection Department or City Department. . .
' construction, and authorize a'representative of the City of.La Duinta Department of Building and Safety to enter
the for which I have applied for this for the purpose of making inspections.
+ApDlicant�f Tz
upon property permit . .
Date
Signature of Applicant or Agent Date
14.APPLICANT Y%. NAME 1L�i. Md�J I1
400 N. 'Rutin Av 1e; Suite 231
CryY/COMMUNITY/STATE/ZIP
Swilm AM, U 92705
// A
CITY/COMMUNITY/STATE/ZIP
1A Qnw, KA 92253
BOK
PAG
PRC"
C
-
T"
RNG
SE
S
TRACT S640-3
44
Plumbing Fee
52.00
Mme'+
.JA
se
TRACT NAME
aa De iii �, Ltd* �
OWNER NAME (L F MI)
CONTRACTOR -FIRM NAME
ADDRESS ..
CITY/COMMUNITY/STATE/ZIP- - -
°t 7f 4} 558-3766
LICNC .
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE M
..
LICNC
USE OF� PERMIT
ii'' (____ .
81.
ZON .
FSB
SSB
SSB
RSB
OFC
ZONE ORD N
LOT SZ.
-END
SIDE:
Print Applicant/Agent Name
APPL/PRMT DATE
1-I&-84
C'M40 -
P=it. to =mt=ct 1,581 Sq. Ft. of S/F/D
with .400 Sq. Ft. of Garage per Approve Plans
M dwdcal Fele
$ 18.00
Plan Check Fee
Pard
CMSt rwtion Fee
400.00
Vjectricai Fee
30:76
SMI Fee
6:20
Plumbing Fee
52.00
Dwelq int Fee
450.00
14 '� ;
$ TOTAL
FEE
$ 955.36
r VALUATION$ 88,200.60
BLDG. DEPT.
Ah
NO.
OPERATION ATE
INSPECTOR
NO.
OPPATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System 00
2
Ftgs & Frms
` — (—`•
G
34
Plenums & Ducts qr•
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
IL
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.
❑
NPON
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
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
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P)
STREET NAME
26 Power Pole
27 Conduit •
28 Service Entrance
29 Wiring
29A Grounding Wire — _ r i (r
29B Bonding
30 Fixtures
31 Service
32 Final �!