001047 (SFD)PERMIT APPLICATION
City of La Ouinta
• Department of Building apn Safety
1
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:
LICENSED CONTRACTORS DECLARATION: I hereby 'affirm 'that I'am licensed .under.provisions of Chapter.:9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class Lic,Nuumber I
'Date Contractor �✓ " * '
v
OWNER -BUILDER DECLARATION: I hereby affirm that lam exempt from the Contractor'sDense Law for he
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a pert/ 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 Contractor's License Law.
(Chapter, 9 (commencing with section,7000) of Division 3 of the Business and Protessions 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 1. 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 will have the burden of proving that
he did not build or improve for the purpose of sale.).. )�
O [,,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.).
•O'1 am exempt under Sec. B. 8 P.C. (Attached Certificate)..
Date ` Owner
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 (Sec. 3800. Lab. C.).
Policy No. Company
O Certified copy is hereby furnished. '
O Certified copy is`filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI)
M. B. Jobnson
ADDRESS
400 N. Tustin Ave. SUte 231
CITY/COMMUNITY/STATE/ZIP
Santa Am. CA 92705
JOB SITE ADDRESS/SPACE
CITY/COMMUNI /STATE2_� _IP_ , _' CA 92253 -
BOK
617
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TRACT NAME - -
Iaguna De is Paz
OWNER NAME (L. F. MI)
aWlicant
CONTRACTOR -FIRM NAME
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ap!rv?11Q�Tit
ADDRESS -
atime
CITY/COMMUNITY/STATE/ZIP �M
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PHONE •
LICNC
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE •
LICNC •
USE OF PERMIT '
S.F.D:
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END. ,
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is .
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
= r• 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:
O I Aereby certify that ho excavation five (5) or more feet in depth into which a person is required to descend, % ill be
made in connection with work authorized by this permit, and that no building structure, scaffolding: falsework, or
w& Abemolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2.' -Art 2, Sec 341, Title B,
C.A.C.)
'O As owner -builder, I will not employ anyone to do work which would require a permit from the Division of-
'Industrial
f'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. C.). - s
Lender's Name "
Lender's Address
I certify that l have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction, and hereby authorize representatives•e
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 l have read this application and stale that
the information given is correct. I agree�to compllygwith`all state laws and county ordinances relating to buidling
constructidnn, and authorize a'repr sentative of thydity� of La Ouinta Department of Building and Safety to enter
• upon theproperty for which I have applied for th's permu for the purpose of making inspections.
Signature of Applicant or Agent Date
Print Applicant/Agent Name f
'APPVPRMT 04
A-19-4
Permit to add additicrai 26 sq. -f.t
Refer back to original permit #0532
Previous bedr m does not Conform as
bin as per TIBC Egress & RAgress
requirements. At no time can this
zona be used as a bedroan.
Ij
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TOTAL-'
FEE
—(1.-•
VALUATION —0,
BLDG. DEPT.
r--1
Ah
NO.
OPERATION DATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
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
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
P/L P/I
STREET NAME
26 Power Polq.
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire .
296 Bonding
30 Fixtures
31 Service
32 Final