0558 (SFD)PERMIT APPLICATION
City of La Ouinta n '. Department of f30ilding and Safety • '
•,
CITY/COMMUNITY/STATE/ZIP .... -
Santa Ana, Ch 92705
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- -This permit -becomes void if work not commenced within 180 days from dale of issuance,
OR, if work. has been suspended or abandoned.for a period'of 180 days.
PAG
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 (5100) o, less. I certify that in the performance of the work for which.this permit is,,. -
(commencing with -Section 7000) of Division Sof the Business and -Professions Code, and my1icense is in full force - -
issued, l shall not employ any'person in any mannerso as to become subject to the Workers' Compensation Laws 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 t6 the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm 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 Seemed revoked:
following reason (Sec. 7031.5. Business and Professions Code: -Any city or county which requires a.permit.to.
T ACi De -ra Paz, Ltd. .•
;at 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 pursuant to the provisions of the Contractor's License Law
...Olhereby certifythat no excavation fW(5)ormore feet indepth intawhichaperson isrequired todescend ',willbe•
• (Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code)or that he is exempt • r
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 disniantling'thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2 Art 2, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.):
C.A.C.)
0 I. as owner of the property, or my employees with wages as}heir 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
USE OF PERMIT
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• • through his own employees, provided that such improvementsare not intended or offered for sale. If, however, the
Division of Industrial Safety Permit No.,
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of proving that
Date Applicant•
he did not build or,imp(ove for the purpose of sale.). - '•,
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the pe4lormance.
0 1, 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
.. - ,..
Contractor's License Law.).
Lender's Address
0 1 am exempt under Sec. B. 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
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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; ora -'.
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certificate of Workers' Compensation Insurance • or a'certified copy -thereof (Sec..3800. Lab: C.).
Signature of Applicant or Agent bate
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF,ENTRY: I certify I 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
' ❑ Cerlified copy is filed with the City Building Inspection •Departmentlor City Department: ...
.• construction, and authorize a representative of the City, of La Ouinta Department of Building and Safety, to enter
. M
• Date ' . Applicant
upon the property for which I have applied for this permit for the purpose of making inspections. -.
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Signature of Applicant or Agent Date
Affle 13: NAME f� L
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40 N. ?L mtin AVeMle, `Wite 231
CITY/COMMUNITY/STATE/ZIP .... -
Santa Ana, Ch 92705
JOBi5E ADDRESS/SPACE_-j.LeSerams
CITY/COMMUNITY/STATE/ZIP.9 53 • • .
La Wini, a, CA
80K
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TY X640-3
LG47
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OWNER Mas F. MI. f
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CONTRACTOR -FIRM NAME ...
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0 558-3766
LICNC .
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC I
USE OF PERMIT
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END
. SIDE
Print Applicant/Agent Name
.APPUPRMT - l ATE 84
Peinit to cm-struct 1,704 Sq, Ft, Of SIP/D
with 400 Sq. Ft. of Garage Per Apprave.i Plans
cal 'Fee
$ 18.900
Plan Clxxk'.Fee
Paid
C7onstruct ton Fee
418.00
Electryca]. F`ee
'32,80
RMI Fee
6,62
Pludp ng Free'
_56,t00
Property Develnt Fee
450.00
A
r FEB
AR
6 283
city et La Quinlo
t.
f .
TOTAL
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5 980.92 ;
VALUATION $94,670.40
BLDG. DEPT.
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
42
Commercial Hood
10
Fireplace P.L.
❑
43
Final S — %ZT
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)
126 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
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring •
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME