001100 (SATT)PERMIT APPLICATION
City of La Ouinta
® Department of Building and Safety
This permit becomes void if work not commenced within 180 days from date of issuance. OR, it work has been suspended.or abandoned fora period of 180 days.
a 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 .
• .(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 mannerso as to become subject tothe Workers'CompensationLaws of
and effect. California.
License Class A _'Lic. Number —?A
Date Contractor,
Jt—
OWNER-BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law f r the
following reason (Sec. 7031.5. Business and Professio s Code: Any city,or county which requires a peftit to
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor'sLicense Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and P•ofessions Code) 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 o1 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 Profess ons Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves Ihereon,arid 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 sold 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. P,
0 Certified copy is filed with the City Building Inspection' Department or City A Department.
Date , Applicant
r J
A�A-
APPLICANT NAME (L, F. MI)
M. D. Janes
ADDRESS'•
2950 Airway Avenue
CITY/COMMUNITY/STATE/ZIP
Costa_ Mesa, CA 92626
JOB SITE ADDRESS/SPACE '
Driveige
CITY/COMMUNITY/STATE/ZIP I
La Qui.nta,CA 92253
BON
PAG
PRC I
C
TWN
FIND
I SE
S
TRACT
18915
LOT
39
Elect. Fee
26.76
MOO SB
m
Bldg. 4
TRACT NAME
Reflections
OWNER NAME (L, F. MI)
14�plicarit'
CONTRACTOR -FIRM NAME..
• above
ADDRESS
above
CITY/COMMUNITY/STATE/ZIP -
above
PHONE • '
LICNC �
345-1,436
DEC 771`4R
ARC/ENG FIRM NAME
Carlson. Slot eDnev ' Hftz nal.hal.ch
ADDRESS
18002 Skvoark Circle
CITY/COMMUNITY/STATE/ZIP .
Irvine, CA 92714
°T4 " -250-0607
LICNC
USE OF PERMIT
Condo
BL
ZON
FSB
SSB
SSB •
RSB
OFC
ZONE ORD 4,
LOT SZ
END
SIDE '
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 I 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,•s
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 Indystrial Safety Permit No.
Date Applicant
f CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this per it is issued (Sec: 3097, Civ. CJ
Lender's Name—T `r /
Lender's Address [.,/.W
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 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'havet'apptied.for this permit for the purpose of making inspections.
_erm
XT /S gnat re f AplaoDate
/
Print Applicant/Agent Name 0
APPWRMT RAl flo
12 DATE11 /84 S.0 .D.
Permit to construct 912 sq. ft.. of
condo plus 26 sq.
ft. of porch and
235 sq. ft. of garage as per
approved pians.
+
Mech. Fee
24.00
Pian Check Fee
246.00
Const. Fee
289.00
Elect. Fee
26.76
SMI Fee
3.64
Plumbing Fee
27.00
Prop. Devel, Fee
450.00
Alrt
DEC 771`4R
TOTAL
FEE
1,066.4n
BLDG.DEPT.
VALUATION 51, 140.00
Ah
NO.
OPERATION DATE
INSPECTOR
NO.
OPER ON DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
��
33
Ventilation System
2
Ftgs & Frms
Qz
34
Plenums & Ducts
2A
Slab Grade
35
36
Furnace Compart. •
Inlets & Outlets
3 Steel
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
1 Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O. X A
NO
ADDITIONAL INFORMATION
.a
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
18 Vents
19 Sewage Disposal .I.
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 PyI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final