0444 (SATT)PERMIT APPLICATION
City of La Duinta
• 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 abando�or pe;of80 ay . , v
x.,
CERTIFICATEOF EXEMPTIONFROM 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 o1 the Business and Professions Code, and my license is in full force issued. I shall not employ any person in any manner so as to become subject to the Workers'CompensationLaws o1
and effect. California.
License Class Lic. Number -Date '1'Applicant.
Date Contractor NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall.
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to be deemed revoked.
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 tofile asigned statement that heislicensed pursuant tothe provisions ofthe Contractor's License Law 0 hereby certify that no excavation five (5)ormorefeet indepth into which aperson isrequired todescend. will be
(Chapter 9(commencing with section 7000) of Division -3 of the Business and Professions Code) orthat he is exempt made in connection'with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, AA 2, Sec341, TitleB,
subjects the applicant to a civil penalty of not more than live hundred dollars ($500.): C.A.C.) I"
• O I. 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.). , .y
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 contraclor(s) licensed pursuant to. the
Contractor's License Law.).
�0.1 am exempt under Sec. - _ . B. 8 P.C. (Attached Certificate).
Date 1' 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. 3600. Lab. C.).'
Policy No. Company X
O Certified copy is hereby furnished. dt7,n�� , .
CO>Certified"copy is filed with I eh City Building Inspect' in Oepa&envoi Cry Department.
Date t 1 ) % Applicant Y
APPLICANT NAME (l• F. rr
(�y^'�i+�1•�v�
ADDRESS -
P. O. B= 780
CITY/COMMUNITY/STATE/ZIP - -
La Quinta., CA 9225'
JOB SITE ADDRESSISPACE
49•-994 El Cisculo
CITY/COMMUNITY/STATE/ZIP
Ia Quinta, CA 92253
BOKPAG
PRC
C
Plan -Check Fee
TVYN
RINGSE
385.00
S
TRACT
14496-1
LOT
164
5.85
PlumbiM Fee
MOD
P-1
SEI
..
TRACT NAME '
Santa Row (rave
OWNER NAME (L, F. MI)
CQON�`RACTAsFIRM NAME ...
a Lf
D '
ADDRESS
CITY/COMMUNITY/STATE/IIP '
PHONE n
564-1315
B
LICNC •
333762
,
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE #
$1,201.85
LICNC P
USE OF PERMIT
SAM with AttachedGaracte
BL
ZON
FSB
SSB SSB
RSB
OFC
ZONE ORO 0-
LOT SZ
..
END
SIDE
❑ As owner -builder, Twill 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.
D Division of Industrial Safety. Permit No.
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. I agree to comply with all
city and county ordinances and state laws relating to building construction, and herebyauthorize 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 whicti I have applied for this permit for the purpose of making inspections.
1k"
Signature of Applicant or Agent Date. .
Print Applicant/Agent Name
APPL/PRMT X44.
12-28-83
t S/F/D
Permit to caastn=t. 1,903 Sq. Ft. of S/F/D
with Attached Garage
Mechanical Fee $
31.00
Plan -Check Fee
250.25
CMIStnictiM Fee
385.00
Electrical Fee
31.25
SMI Fee
5.85
PlumbiM Fee
48.50
Property Dojelammt Fee
450.00
r r
}
PY
B
tir--
0 t V Z 1963
CRY.
- F�- 0: `tea Q'''(, in'la ✓
TOTAL
FEE
$1,201.85
BLDG. DEFT.
VALUATIONI$ 83,889.80
Ah
I -
NO.
OPERATION 'OFATE INSPECTOR
NO. OP RATION. DATE INSPECTOR
BUILDING .APPROVA•LS
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 '
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 Lath
12A Drywall4,IrT
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
20 Sewer
21Water Heater i
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
29B Bonding
30 Fixtures
31 Service
32 Final
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