0541 (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 ha's been suspended or abandoned for a period of 180 days...
• + .
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 full force,
issued, I shall not employany 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 Contractor'
NOTICE TO APP.LICANT.:.If, after making this Certificateof Exemption; you should become subject to the Workers'., .
OWNER -BUILDER DECLARATION: I hereby'atfirm that I am exempt from the Contractor's License Law for the'
Compensation provisions of the Labor. Code, you must.forthwith comply 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
A50
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 tolile.asigned statement that heislicenseppursuanttolheprovisionsoftheContractor'slicenseCaw •.
❑ 1herebycertifyth'atnoexcavatiorifive(5)ormorefeetiri'depthintowhichapersonisrequiredtodescend;Wiill be
(Chapter 9 (commencing with section 7000) of Division Sof the Business and Professions Code) or that heisexempt . • .
made in connection with ivork 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 permitDemolition
or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, 7itle8,-
subjects the applicant to a civil penalty of not more=than five hundred dollars ($500.);
C.A.C.) %=� V` * • ", -
• ❑ I, as owner of the property, or my employees with wages as theirsole 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 .
- -
through his own employees, provided that such improvements are not intended oroffered for sale. If, however, the ,.
0 Division of Industrial Safety Permit No.
building orimprovemnt is sold within one year of completion. the owner -builder will have the burden of proving that
Date Applicant
he did not build or improve for.the purpose of sale.). . • _ . 1.1;11. '.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for.the'performance '
❑ I, as owner. ofAhe property, am exculsively contracting with licensed contractors to constiuct.the project (Sec.- s
of the work for which this permit is issued (Sec. 3097, Civ. C.).-
.):7044.
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•th'ereon, and who contracts for such projects with acontractor(s) licensed pursuant to the
-
Contractor's License Law.).
Lender's Address
• 0 l am exempt under 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 J
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 td 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: 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
O Certified copy is filed with the City Building Inipectioh'Depaftment'or City Department:
a—sy���w�_
construction, and authorize a'representatiye of the City of La Ouinta Department of Building and Safety to enter.
• Date Applicant
uporcthe property for which I have applied for this permit for the purpose of making inspections: . .
Signature of Applicant or Agent Date
I
APPLICANT NAME (L. F, MI) - Y
He be LXXVLSM
A400 N. Tustin Avenue, Suite 231
CITY/COMMUNITY/STATE/ZIP
Santa Ana, CA 92705
JOB MS ADOr�'RIESS/'SPAC�E�
ams LIS 133
CITY/COM��.•.•�I.T6y�•6.•/_S�TA�ie�al�A • 92253
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Plutbing Fee
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TRACT NAME De � ,. Ltd*
OWNER F. MI)
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CONTRACTOR -FIRM NAME '
ADDRESS -
CITY/COMMUNITY/STATE/ZIP "
Pt, ii) 558-3766 `
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ARC/ENG FIRM NAME•
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
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SIDE,
Print Applicant/Agent Name
APPL/PRMT flS /4 1 1-•2444
omoo
Pezm t to cimotruct 10894 Sq.
Ft, of S/F/D
with 400 Sq. Ft, of Garage Per approvei Plms
A3ech�iriir,�1 Fee
$ .. 18,00 '
Plan Check Fee
Paid
fbnstructich Fee
445,50
Electrical'Fee
-.34067
SW res
7932
Plutbing Fee
61,00
PA=Y Dervelopmimt Fee
A50
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L Ly
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f TOTAL
FEE
1,016.49
V1,016.49
BLDG. DEPT.
VALUATION -?104,664A0 '
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Ah
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAI,APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
- _ b`�
_
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
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final ".V --
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 Wal.ls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)'
14 Final
PLUMBING APPROVALS
15 Ground Plumb (! — / -Y
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 4',G.
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
29B Bonding
30 Fixtures
31 Service
32 Final �7•Kl�gt� gi