0448 (SATT)PERMIT APPLICATION
City of La.g a
Department of Building and Safety
This permit becomes void if work not commenced within 160 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: 1 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 Sol the Business and Professions Code, and my license is in full force issued) shall not employ any person inany manner so asto become subject to the Workers'Compensation Laws of
and effect. California.
License Class Lic. Number
Date' Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I ani 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) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicamllor a permit
subjects the applicant.to a civil penalty of not more than five hundred dollars (5500,): ,,.••(-nu -
O 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, 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 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.).
O 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.).
.O 1 am exempt under Sec. . B. 6 P.C. (Attached Certificate).
j Date _ . ' ° Owner
II WORKERSCOMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
i certificate of Workers' -Compensation Insurance , or a certified copy thereof (Sec. 3800: Lab. C.).
Policy No. Company
O Certified copy is hereby furnished:
",Q/Certified copy is filed with the City Building Inspectio nDepartmen, orddCity^� Department.
Date. { " % Applicant.
0 Vr
NAM_-. (L, F. MI)
APPLnc E '
klu
ADD.
P.RE0. Bmc 780 ..
CITY/COM MqN ITY/STATE/ZI P
La QiI nta, CA 92253
4 �E83 REFS/SPAC
CITY/COMMUNITY/STATE/ZIP
La QAnta, Ch 92253
BOK
'PAG
PRC
C
Plan Check Fee
TWN
RNG
SE
S
14496-1
1681.
5.57
Plimbing Fee
P�- 2
SB
I
300.00
E
NERECGEF
OWNER NAME (L. F. MI) -
CONTRACTOt SIRM bO •.
AS�7WV�
ADDRESS .
CITY/COMMUNITY/STATE/ZIP
564-1315
333762
I Cu 1
.0 is MJ
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
$1,031.77
LICNC N
USE OFMIT
with Attached Garage
BL
ZON
FSB
SSB
SSB,
RS8
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'
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:
O l 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 B.
C.A.C.)
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.
❑ 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.l 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 `
I CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I.certify l 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 have applied for this permit for the purpose -of making inspections.:.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT • DATE
4 12--28•-83
S/F/D
Permit to caaist.rimt 1,812 Sq. Ft. of S/F/D
with Attached Garage
Mect�uiical Fee $
31.00
Plan Check Fee
242.45
Construction Fee
373.00
F1ect?c3ca1 Fee , ,
31.25
SMI Fee
5.57
Plimbing Fee
48.50
Prgpert-y Developnent Fes
300.00
I Cu 1
.0 is MJ
aty f �i i �yCoF v
TOTAL
FEE
$1,031.77
BLDG. DEPT.
VALUATIONI$ 79,103.20
�
NO.
OPERATION ATE
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 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 Y
8
Vents
41
Smoke Detection Device
9
Garage Fire•Wall
42
Commercial Hood
10
Fireplace P. L.
0'
43
Final
10A •
fireplace T.O.
0
NOADDIT..IONAL'INFORMATION
/g
'
SEWAGE.SYSTEM S12E &LOCATION
11 Exterior Lath
12. Internal Lath
12A Drywall
13 Finish Grade
R
INSULATION Thick
Valuej
7A Walls (Batts)
12B. Ceiling (Batts)
12C Ceiling (Blown)
14' Final
PLUMBINGAPPROVALS
15 Ground Plumb 71714/,
• 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 P/L
STREET'NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
290 Bonding
30 Fixtures
31 Service
32 Final
-.1
c.: