0858 (SFD)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 for a period of 180 days.,
LICENSED CONTRACTORS DECLARATION:I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section -7000) of Division 3 of the Business and Professions Code• and my license is in full force -
r d effect.
(License Class jLic. Number f 1A
.Oates/ •4x Contractor,/;'--;�
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the -
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit 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's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code)orthat heis 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.):.,x4 -. -
,y 0 1. 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, avid 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 orimprovemntissold within oneyearofcompletion, the owner -.builder will havethe burden of provingthat .
he did not build or improve for the purpose of sale.).
0 1• 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 a exempt under Sec. . B. 8 P.C. (Attached Certificate).
Date ``I " Owner.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that 1 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. - -
'! VL-' Certified copy is with the City Building Inspection Department or City Department...
Date! Applicant��.71-1 A r/r fl
n �r
APPLICANT NAME (L. F. MI(Fk�ad It �micb^^wl
ADDRESS '
P.O. Dam 1.23
CITY/COM MUNI TY/STATE/ZIP
La Qui &a,. CA 92253
JOB SITE ADDRESSISPACE -
54-385 Ave. Diaz
CITY/COMMUNITY/STATE/ZIP
Fa Qxinta. CA 92253
BOK
774
'PAG
2333
PRC
07.8
C
TWN
RNG
SE
S
TRACT
LOT
322.00
MOD
SS
SMI Feet
TRACT NAME '
OWNER NAME L. F. M1)
NOS. ^ Wnbael
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE /
\937.58
(230/00)
LICNC .
707.58
ARC/ENG FIRM NAME - M,
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
/may
LICNC 0
. .
USE OF PERMIT ,
Single Family Dwallim
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZONE ORD, •
LOT *SZ
END
SIDE.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is .
issued, I shall not employ any person in any manner so as to become subject to the Workers -Compensation Laws of
California.
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: xr�
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; Sec341, 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 Safely 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. l 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'repres'entative of the City of La Ouinta Department of",8uilding and'Salely to enter
upon the property for whicjl Ihave applied for this permit for the purpose of.making.inspections.
Signature of Applicant'or Agent Date
Print Applicant/Agent Name
APPL/PRMT
RA.R II. �(/■ -.9-R4
DATE
S.F.D.
Pprmli 4- 4-^
sincrle family dwelling n and 400 "sq. ft.
of gargaraW an per amrmpirl n F#t1
Mach. Fee. �
16.00
plan Check
209.30
Cehst. Fee
322.00
Flect Fee
38.40
SMI Feet
4.38
Plumbing Fee
47.50
Property Dev.
300.00
01wviuly Pd.
\937.58
(230/00)
707.58
�t
TOTAL
FEE
/may
BLDG. DEPT.
VALUATION Q,820.80-
5s5
NO.
OPERATION DATE INSPECTOR
NO..
OPERATION DATE INSPECTOR
BUILDING -APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs &.Frms
34
Plenums & Ducts
2A
Slab Grade
'35
Furnace Compare.
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.
❑
NON ADDITIONAL INFORMATION
SEWAGE SYSTEM,SIZE & LOCATION
11 Exterior Lath p2�
12 Internal Lath
12A. Drywall
13 Finish Grade
INSULATION Thick Value.
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING,APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb eJ
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 P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29. Wiring i
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final.