001070 (SATT)PERMIT APPLICATION i
City of La Duinta
• Department of Building and Safety •
This permit becomes void if work not commenced within 1B0 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 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).ol Division 3 of the Business and Professions Code: and my license is in lull force issued, I shall not employ any person in any manner so as to become subject to the Workersompensation Laws of
and effect. California.
License Class I ic. Number +--�-- _ Date Applicant
Date Contractor• A NOTICE TO APPLICANT: If, after making this Certificate•o1 Exemption, you should beco subject to the Workers
Compensation provisions of the Labor Codeyou must forthwith comply with such provisions or this permit shall e
OWNER -BUILDER DECLARATION: I hereby affirm that am exempt from the Contractor's License La6' , r the be deemed revoked. `�
following reason (Sec. 7031.5. Business and Professjons Cade: Any city or county4hich requires a permit to
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 pursuanttotheprovisions oftheContractorsLicense Law 01 hereby certify that no excavation five (5) or more fiet 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.Pr)fessions Code)or that he is exempt made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and;thp basis -for the alleged exemption. Any violation of Section 7331.5 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, Sec 341, Title 8,
subjects the app licant.to a civil penalty of not more than five hundred dollars ($500.): C.A.C.) 4- »:
..0 I, as owner of the •property, or my employees with wages as their sole compensation,. will do the work, and the CFAs 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 his 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
through his own employees, provided that such improvements are not intended or. offered for sale..lf, however, the 0 Division of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion,theowner-builder will havethe 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 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:1C.).
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. 8 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
DateOwner city and county. ordinances and state laws relating to building construction, and hereby authorize representatives
of this cou3lty 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 , or a certified copy.thereof (Sec. 3800. Lab. C.). Signature of Applicant or Agent Date i.
Policy No.Company CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that Ki
0 Certified copy is hereby furnished. s • • • - . , the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
O� Certified copy is filed with the City Building Inspection. Department or City Department... construction, and authorize a'representative of the City of La Duinta Department of Building and Safety to enter
upon the property for whiit have a plied -for this permit for the purpose of making 'nspec ions.
Date Applicant loLv ate_ Aj �f A% t. s
Signal re of Applicant,or Agent ` —Date
C/ %,4111), .�-a; L�4
lei -35"Print Applicant /Agent Name
APPLICANT NAME (L. F. MI)
M.D. Janes. Co.
ADDRESS
50 Airwakv Aim- Suitt- tfa D
CITY/COMMUNITY/STATE/ZIP
Costa Mesa. CA 92626 '
JOB SITE ADORESS/SPACE
CITY/COMMUNITY/STATE/ZIP
La i.nta. CA 92253
BOK
PAG
PRC-
C I
TNN
RNG
SE
S
T ACT
4915
LOT
246.00
Const. Fee
MOO
2
SB
W"L
TRACT NAME
Reflections
OWNER NAME (L. F. MI)Arm,
l .alit
1i�
(
CONTR�sPOY.:F1l�:GJ�t
En
ADDRESSC'Lr
above
CITY/COMMUNITY/STATE/ZIP ,
above
P"°345-1436
I
1.LICNC 0
ARC/Eilklit IAM�napp Architect -
ADDRESS
3400 Iriine Ave.' -# 205
CITY/COMMUNITY/STATE/ZIP -
Newport Beach, CA 92660
PNNE 0
7D14-979-8842
TOTAL .
FEE
UCNC.
'
USE DFSingle Family Dwelling
BL
'ZON
FSB
SSB
SSB
'RSB
OFC ..
^
- ZONE ORD 11.
LOT -SZ
• END
SIDE'.
APPUPRMT- fl n n 7 o
- DATE
12-4-84 S.F.D.
Permit to construct 912 sa. £t„ of
and 26 sq. £t of porch and
235 an. ft. Af ca
,aimp- as ner artrtrow
n . S.
Mech. Fee
24.00
Plan Chhck Fee
246.00
Const. Fee
289.00
Elect,. Fee
26.76
SMIN Fee
3.64
Plumbi,na Fee
27.00
Prop. Devel• Fee
>a50.00
PAID OR 5
19LA
TOTAL .
FEE
BLDG. DEPT. VALUATION
M
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
—/ Z
C,
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
—/'t —S/
'`�C,.
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.
p
❑.
43
Final .. �3 8 Vie.
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 Ceilinj (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 — c _ G
Tank Pit L. Line
ELECTRIC APPROVALS,
REAR OF PROPERTY LINE
P/L P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final