0533 (SFD)• PERMIT APPLICATION
City of La Og a •
' • 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.
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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,: '.
J
(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 anyperson in any manner so as to become subject to the Workers'CompensationLaws of
and effect.
California.
License Class. Lic. 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 tfie•'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit,shall .
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following 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:
such permit to fileasignedstatementthatheislicensedpursuanttotheproyisionsoftheContractor's'LicenseLaw- .
O•Iherebycertifythat noexcavatiolifive(5)brmbrefeet indeptffinto which aperson isrequired todescend, 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 bytKis 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 permit
demolition or dismantling thereof:.will tie more than thirty-shz (36) feethigh. (Chap 3.2, Grp 2 Art 2, Sec341, Title8.
subjects the applicant to a civil penalty of not more than five hundred'dollars ($500.):
CAC) r .arL • '
' O I, as owner of the property, or•my employees with wages as their;sole compensation, will do the work, and the
❑ As owner -builder, I will not'employ anyone to-do work which would require a permit from the Division -of
struclure.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
ADDRESS
through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
O, Division of Industrial Safety Permit No.
• building or.improvemntissold within one year ofcompletion, the owner -builder will have the burden of proving that..
Date Applicant
he did not build or improve.foc the purpose of sale.). . - x ,
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency performance
' O I, as owner of the property,'amtexculsively contracting with licensed contractors to construct the project (Sec:
:ol the work4or 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 -
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Contractor's License Law.). _..,
Lender's Address
❑ 1 am exempt under Sec. B.,&-P.C. (Attached Certificate): =
.. I certify that I have read this application and state that the above information is correct.) 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, or'a
certificate of Workers"Compensation Insurance ; or a certified copythereof (Sec: 3800: Lab. Q.
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify l have read this application 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 .
❑ Certified'copy is Tiled with the City Building Inspection.Department,,or-City 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 have applied for this permit for the purpose of making inspections. .
Date Applicant
Signature of Applicant or Agent Date
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Plumbing Fee
58,50
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CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE .W 558v-3766 \ -
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% 9 6' 75
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ARC/ENG FIRM NAME . .
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE .
LICNC .
USE JO2J10 IT(CondaL1,A•114 um)..
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Print Applicant/Agent Name
APPL/PRMT RAL `J -J 1-400,84
Ccnc )'
PeMit too =ist=ct 1,662 Sq. Ft, of S/F/D
with 400 Sq. Ft. of _Garage Pier Appraved.Plan
t
Ichanical. 'Fee
$ 18.00
Plan Check Fee `
Paid
Cmistractian Fee
.412.00
Faectrlcal Fee
31.77
SM Fee
6,48
Plumbing Fee
58,50
Property Development Fee
450, 00
R E C E,:9vEa
VFEB 6 19,83
✓&ems
r tl ...c w. ..' .. _•
TOTAL '�
FEE
;
% 9 6' 75
•
VALUATION " 92,461.20
BLDG. DEPT.
Ah
rI
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts Ap
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.
❑
OP'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
16 Water Piping
17 Rough Plumb ft—
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 PiI
STREET NAME
26 Power Pole IL
27 Conduit •
28 Service Entrance
29 Wiring a
29A Grounding Wire / /— (—� ( G
29B Bonding
30 Fixtures
31 Service
32 Final It G,