0530 (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...
,PJ1P.IC 17.�ViiiLl�lF� ML.%iMADDRES.,
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE. This section need not -be completed U -
;LICENSED CONTRACTORS DECLARATION: I hereby affirm that 'I am-.Iicensed 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 inany manner so asto become subject to the Workers Compensation Laws of
and effect.
California.
License Class. Lic: Number
Date Applicant
Date >• • - = Contractor'
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption..you should become subject.to;the,Workers'
•
OWNER•BUILO�R•DECLARATION�` I hereby affirm that I am exempt front the Contractor's.License Law for the
Compensation provisions of -the Labor Code, you must forthwith comply with such provisions or this'permit shall r-
following reason (Sec. 7031.5, Business and Professions Code: Any, city orcounty which requires a permit to
be deemed•evoked.
-r
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 file a signed statement,that he is licensed pWsuanttothe provisions ofthe Contra.ctor5 License Law
p'Ihereby certify that noexcavationfive (5)ormorefeetindepthititowhich apersonisrequired todescend,willbe
(Chapter 9(commencing with section 7000) of Division of:the•Business and Professions Code) or.thathe isexempt
made in connection with work authorized by this'permiti and,that no building structure, scaffolding; talsework, 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 be more than thirty -six -(36) feet high..(Chap 3.2. Grp 2:A -rt .2; Sec341, Title B,'
subjects the applicant to•a civil penalty of not more than five hundred dollars ($500.):
C'.A.C.)
O 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. If, howevercthe
0 Division of Industrial Safety Permit No.
building or improverrint is sold within one year of completion, the owner -builder will haMtIte burden.of proving that .
Date Applicant.'
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby.affirm that there is a construction lending agency for the performance
0.1 *
t; as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
of the work forwhich this permit is issued (Sec. 3097, Civ. C.).
7044, Business and Professions Code: The Contractor's License law does not apply town owner of property who .
Lenders 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
'. ❑ 1 am exempt under -Sec. • ..B. 8 P.C. (Attached.Certificate): •
I cenity that I have read this application and state that the above information is correct. I agree to comply with all
Owner
city and,county ordinances and state laws relating to building.construction, and -hereby authorize representatives
..Date
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 , ora certified copy thereof (Sec. 3800. Lab. C:)r .-.
$ignature.of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this applicationand state that !w.
❑ Certified copy is hereby furnished:- ,a ..
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling .a�'a
❑ Certified copy is filed with the City Building Inspection De artment_gr,Cify• ' Department.,,.
- , . ' construction, and authorize a'representative of the City of La Ouinta Department of Building and, Safety to enter
� � _.
_ - 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
,PJ1P.IC 17.�ViiiLl�lF� ML.%iMADDRES.,
400 N. Tustin Avenue, Su4 a 231
CI_Tg/COZa NIT�YY/yS,T�A;E/ZIgT '9270.5
JYS AODRESS/SP,ACErar
y9
— 1T�AFE/Zc� 92253
BOK
.PAG
PRC
- C
Mechanical Fee•. $
TWN
RNG
SE
S
TRACT,
LO1 1 T,
sa
29.32
.
I
MOD
sB
40.50
TRACT NAME T ., y�
ij aI9tua De La Paz � Ltd.
0��e Mas FB .. . .
CONTRACTOR -FIRM NAME • ' •.
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHO/A.4) Z8 -37r56
RE C -LB
:1
L�°"° •
x
Ft8 b '1983
_ T
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE N
-
LICNG.I.
.-
USE 0& PERMIT
alt -113 (C ;*4dU )
BL
ZON
FSB
SSB
SSB .-'RSB
OFC .
ZONE ORD -Ir
LOT SZ
END
Print Applicant/Agent Name
APPL/PRMT - i R SI
Wnd.o..
Pemit to oonstrimt 1,466 Sq. Ft.
of S/F/D
with 400 Sq. Ft. oC Garage per ampxovad
Plans.
Mechanical Fee•. $
18000
Plan Check -Fee.
Paid
omistrtcticn - Fee
382.00
Electrical Fee "
29.32
SMI Fee
5.78
Plunbing Fee
40.50
Property Dunt Fee_
450, 00
RE C -LB
:1
V ED
x
Ft8 b '1983
_ T
- TOTALT•.'
' FEE
925.60
- BLDG. DEPT.
VALUATION 582,,161.60
-
r-1
Ask
NO.
OPERATION ATE
INSPECTOR
NO.
OPPATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICA APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
�! L —��
C
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.
❑
NON
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)
�r
14 Final 4..
PLUMBING APPROVALS
15 Ground Plumb —#tt-1JA-f -
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 Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final