0528 (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.
CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE: This section need not be completed If
LICENSED CONTRACTORS DECLARATION: l: 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.70DO) of Division 3 of the Business and.Professions Code, and.my license is in full force issued, I shall not employ any person in any manner so as to become subject tothe Workers'Compensation Laws of
and effect. - California.
License Class Lic. Number
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
fh
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Cbntractor's License Law for the
Compensation provisions o t e 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
JOB7 vY "'4,KYJE-PAC a3
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 thathe is licensed pursuant to the provisions of the Contractor's License Law
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) orthat 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 a.permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2. Art 2, Sec341, Title B,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
%' C.A.C.) .
0 I. as owner of.the property, or my employees with.wages as their sole compensation, will do the work, and the
0 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
so sB
through his -own employees. provided that such improvements are not intended or offered for sale. If, however, the
0 Division; of Industrial Safety Permit No.
building,or improvernnt is sold within one year of completion, the owner -builder will have the burden of provingthat
Date Applicant
he did not build or improve for the purpose of sale.). ;1
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
0 I, 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: 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
ADDRESS
Contractor's License Law.).
Lender's Address
' 0 f 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. I agree to comply with all
Date Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
BL
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.)..
Policy No. Company
0 Certified copy is hereby furnished. ,
0 Certified copy is filed with the City Building Insp6ctibn,DepartmenLor City —' 1 • Department.
Date Applicant �
APP
♦'iLICANT YY• NAf.IE�(L; •F.pY�sf/SMD -
• SKxi
"D►U N• Tustin Aveme, Suite 231
CI T.YJCOMMUN ITY/STATE/ZIP
i x ay ..A 92705,
�'�
JOB7 vY "'4,KYJE-PAC a3
CI COM�MYU"Y/ oij,E21P•A 92253 -
BOK
PAG
PRC�Lt!
C
Plan Check Fee
TWN
ING
SE.
S
TT''640,3
`J 7
6.20
P1ng Fee
MOO
so sB
450.00
T"4-:NAUM�E.iii. tw Paz,,Ltd.
OWERIZMU!F.4
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHO `3 558-3766
198 *4
LICNC I
CRYP o " -
aoS ter« Qui�a�C;
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC 11
USE OFPERMITt
i '
BL
Z`ON
FSB
SSB
SSB
RSB
OFC
ZONE ORO N
LOT SZ
, END
SIDE
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
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.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT AT
R • R } �. � 1 G"84
Pen4i t to construct '1,581 Sq. Ft.
of S/F/D
with 400 Sq. Ft. of Garage per 4Vramd dans
Mechanical Fee
$ 18.00
Plan Check Fee
Paid.
Cga�sttuctian Fee
400.00
Electrilcai Fee
30.76
SMI Fee
6.20
P1ng Fee
51.00
Prgx ty Development Flee
450.00
L/
198 *4
CRYP o " -
aoS ter« Qui�a�C;
TOTAL
' FEE
VALUATION tlikl,CCJli.btl
BLDG.DEPT.
r1
Ah
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION I 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
to
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final ..���� g� [•.
10A
fireplace T.O.
❑
NO
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick VVaalulu e
7A Walls (Batts) •
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb I 1— I — g -,i�L-G
16 Water Piping cow
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(I
STREET NAME
26 Power Pole
27 Conduit •
28 Service Entrance
•
29 Wiring
29A Grounding Wire ,�� C
29B Bonding
30 Fixtures
31 Service
32 Final