0860 (SFD)LICENSED CONTRACTORS DECL'ARATI
(:ommencing with Section 7000) of Divi
End effect. //
,4{{''Licens_e Class�j � tic. Number •`
0ate ,•�, j 7i%" (•� Contractors '? <i, r {� a1./.
s /
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
suchpermit.tofile asignedstatement thatheislicensed pursuant tothe grovisionsofthe Contra ctor'sLicense Law .
(Chapter 9(commencing with section 7000) of Division 3of the Business and Professions Code) or that 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 live hundred dollars ($500.): -
0 I. as owner of the property. or my employees with wages as their so`:e 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 of 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.).•V ,
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
Coniractor's.License Law.).
0 1 am exempt under Sec. ' B. 8 P.C. ,(Attached Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: •1 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. Q.-, •
Policy NO. Company
❑ Certified copy -is here7b ,furnished.
Ce.
tiliedycop s,liled'With the City Building Inspection Department or City Department.
Date fr/ i-APPlicant/ /ryi%4 "r'.!s:
PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
.S y - qD
This permit becomes void it work not commenced within 180 days from date of issuance. OR, if work. has been suspended or abandoned for.a period of 180 days.
r
CERTIFICATE'OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This -section need not be completed if
ON: 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
s
ion 3ofthe Business and Professions Code, and mylicense.isin.fullforce ,} issued., I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
^ California.
.APPLICANT NAME (L. F. MI) +�
�eac3. � M�LIc�'>tac•+
ADDRESS -
P.O. Box 1.23
CITY/COMMUNITY/STATE/ZIP '
Lal Qui nta. � 92253
JOB SITE ADDRESS/SPACE -
SA—tins Ave. maa
CITY/COMMUNITY/STATE/ZIP -
La (Iii '1tta.. 92253
BOK
774
PAG
233
PRC
019
C
- . TWN.
RING
SE
S ,
TRACT
LOT
MOD
SB
TRACT NAME '
OWNER NAME (L. F, MI(
mad . MiuGl '
CONTRACTOR -FIRM NAME
ADDRESS `
v
CITY/COMMUNITY/STATE/ZIP -
Oak
PHONE •
LICNC0
ARC/ENG FIRM NAME *
1
ADDRESS
• G`
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC N
USE OF PERMIT '
SL
ZON
FSB SSB_
SSB RSB'
OFC
. ZONE ORD N
LOT SZ
END
'SIDE
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption: you should become subject,to the Workers'.
r
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, An 2. Sec 341, Title 8.
C.A.C.) ' M
O'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: 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.
n
CERTIFICATE OF COMPLIANCE�AND AUTHORIZATION OF ENTRY: I certify I have read this applicatiipand state that
the information given is cbrtect. I agree to co_m6ly with all state laws and county ordinances relating to buidling
construction. and authorize a'representative of thetity of La Duinta Department o1 Building and Safety to enter
$pon the;piopehy for which -have applied for this permit for the purpose•of mAing':inspeeTions,
v r
Signature of Applicant or AgJnt / Date
Print Applicant/Agent Name
APPL/PRMT DATE
7-18-84 S.F.D.
Permit to anstruc t 1232 sof., £t
sinala family l na and 400 fix �.
o£ as as � TY . Talanf
mech. POP
IL1s QLA ••
Plan Cl*k 209 -In
Elect. Fee 38.40
SMT rpo A R
Plumbi nc±r Faa A _ SO
Pzoperty DeQ. 300.00
417 SS
Previous la Ptd,. (230.00)
707.58
TOTAL
FEE 7n7/ro
BLDG.DEPT.
VALUATION 62,820.80.
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE INtSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs &• Frms
0
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.
❑
NOADDITIONAL INFORMATION
SEWAGE' SYSTEM SIZE & LOCATION
11 Exterior Lath
12 .Internal. LathrG/�'�'�./
12A Drywall /
13 Finish Grade
INSULATION . Thick R"
Value
7A' Walls (Batts)
126 Ceiling (Batts)
12C Ceiling (Blown).
14 Final
PLLIMB ING:AP_ ROVALS
15 Ground Plumb % �p
16 Water Piping
17 Rough Plumb d
18 Vents
19 Sewage Disposal
20 Sewer �Q
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 P/L
•f
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance:
29 Wiring L
29A Grounding Wire'
29B Bonding
30 Fixtures
31 Service
32: Final
it