001385 (SFD)PERMIT APPLICATION
City of La Oug 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: I hereby affirm that I am licensed under provisions Wthapter 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 forceissued. I shall not employ any person in any manner so asto become subject to the Workers'Compensation Laws of .
and effect. California.
License Class Lic. Number���
.Date Contractor .A- y- 'r f
a
OWNER -BUILDER DECLARATION: I Kereby'affirm that I am exempt from the, ontracor's License Law for the
following reason (Sec. 7031.5. Business and Professions Code:. It city county which requires a permit to
construct, alter, improve. demolish, or repair any structure, prior to its rssuan , also requires the applicant for
. . such permit to file a signed statement,that he is licensed pursuant to the provisions oft e Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Cade) 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.):
0 I, 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 improvemnt is so Id 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.).
0 I, 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.).
0 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; or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800: Lab. C.). .
Policy No. _ Company
0 Certified copy is'hereby,furnished. .. .. • •.
0 Certified copy is fifed'with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI) JL C=13t=CtJXM
ADDRESS P.O. 173
CITY/COMMUNITY/STATE/ZIPNwtor' M 92053 .
JOB SITE ADDRESS/SPACE 9�--030 g5. s=6= -.m
„m lamst brit
CITY/COMMUNITY/STATE/ZIPLa C / CA, 92253
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307.96
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TRACT NAME IMMM? P Tra
OWNER NAME (L. F. MI) LL.iSL�E.�l N-�"-r�•
CONTRACTOR -FIRM NAME J.L. ����
ADDRESS
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CITY/COMMUNITY/STATE/ZIP fOAiV ' .
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PHONE M -
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LICNC N
ARC/ENG FIRM NAME * N �A!-3C=.A!-3C=.A!-3C=.ADDRESS 1340
S. F _ �nl Dr.A212
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CITY/COMMUNITY/STATE/ZIP
JGG
CA 92262
PHONE 0 -7097
862.60
LICNC N323
USE OF PERMIT single FY. -Aly a -m •0 in'l
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TOTAL
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END
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Date Applicant
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:
0 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or`
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2; Sec 341, Title 8.
C.A.C.)
0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
0 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.).
Lender's Name
Lender's Address
I certify that I 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
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 cefy I have read thisapplication and state that
the information given is correct. I agree to comply witpi�aalll stat le aws and county ordinances relating to.buidling
construction, and authorize.a'representative of -the City oVf La ouinta Department of Building and Safety to enter.
upon the property<for,which I have applierorsthis�pe'rmit for the purpose of making inspections.
Signature of Applicant of Agent Date
Print Applicant/Agent Name
APPL/PRMT 1�,"�� l"0} t
1}JJ} j} tt i 1!
4 8L�
7
X.D.S
permit to C3II7l..rt$gIat 12E47 cq. ft.
of
living area and 433
sq. ft. of
ac par -7=ovzd plms.
r^4sch.
37.00
Plan Chzdc Fee
307.96
Omst. rt3
367.00
Fick. Fc -3
60.18
8-2 F
5.Ora
pitalaing
85.00
.FC2
862.60
(3.05.72)D. MM
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TOTAL
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A1113
BLDG. DEPT.
5 22 7
VALUATION
a
A&
NO.
OPERATION DATE
INSPECTOR
NO.
ERATION 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
10A
Fireplace T.O.
❑
OP'NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
t2A 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. PiI
STREET NAME
26 Power Pole
27 Conduit
28 ' Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final