0420 (SFD)PERMIT APPLICATION +
City
Department
of La Ouinta
Building Safety •
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and , . + . , r
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• This permit becomes void if work not commenced within. 180 days from date
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of issuance, OR; -if work. has been suspended orabandoned;for a period,of 180 days. :+ ..:: • f .•-: -.
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- 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. l certify that in -the performance of the work for.which this permit is
(commencing with*Section 7000) of Division 3 of the'Business and Professions Code; and my license is in lull force- ;
issued, l shall not employ any person inany,mannerso. s to become subject to the Workers' Compensation Laws of ;
and effect.
California. ,
License Class Lic..Number
Date Applicant
Date Contractor " ^-
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to.the.Workers d
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 musliorthwith comply with such provisions or this permit shall , ri
be deemed revoked. '
,. following reason (Sec. 7031.5: Business and Professions Code: Any city or county, which requires a permit to .
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construct, alter, improve, demolish, or repair, any. structure, prior to its imance,.also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: „. r
; such permit to file a signed .statement that he is licensedoursuantlgthe.provisionsofthe Contractor's License Law .
•' O 1 hereby'c0tify that no excavation five (5) or,moire feEl indepth into which,a person is required to descend; will be - �f a
(Chapter 9(commencing with section 7000) of -Division 3 of the Business and ProfessionsCodejor that he is exempt
'made in connection with work authorized by this permi , and that 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 thi Ity-six (36) feet high.,(Chap 3.2, Grp 2 Art -2, Sec 341, Title 8, _
•, subjects the applicant to a civil penalty of not more than five hundreddollars ($500.): , -
C.A.C.),- • ' - ° Y'a%�=�•- _, _
•.. ❑ I, as: owner of the property, or my employees with wages as their sole compensation, will do the work, and.the .
0 As ownef-builder' I will not'employ anyone to do work which wouldrequire a permitfrom the Division of.
structure is. noNiotended or offered for sale (Sec..7044,.Business and Professions Code: The Contractor's License
Industrial Safety, as notedabove. unless'such personlhas 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. <.
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` tnrough his own:employees: provided that such improvements are not intended or offered,for sale. ll, however; the .
O Division of Industrial Safety Permit No.
• building orimprovemntissoldw(ithinone year ofcompletion,the owner -builder will have the burden ofprovingthat
Date iApplicant
he did not build or improve for„the purpose of sale.).. ; ,lr
CONSTRUCTION LENDING AGENCY: I hereby affirm.thaMhere is a construction lending agency for the performance .
o 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. C.):: '
• 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
•?' 0A am exempt under Sec. B..B. P.C. (Attached Certificate). -;
I certify that I have read this application and state that :he above information is correct I agree.to comply with all ,
Date' Owner
cityand county ordinances and state laws relating to b Wiling construction, and hereby authorize representatives '
of this county to enter upon the above-mentioned pro,�erty for inspection purposes. ;
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of .consent to self -insure, ora
• .certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec} 3800. Lab. C.). ,
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Signature of Applicant or Agent Date
Policy No, Company
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CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:. I certify I have read thisapplication'and state that .
O Certified copy is hereby furnished. - �� 1 o r
the information given is correct. I agree to comply with allstate laws and county ordinances relating to buidling .
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17/Certifiedcopy is filed with the City'Buildirig Inspection Department, or City Department.
. . construction, and authorize a' representative of the Ciy of La,.Ouinta Department of Building and Safety to enter >• • ,
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upon the properfy,for which I have applied for this permit for.the purpose of making inspections.
/ MDlicant
APPLICANT NAME (L.
ADDRESS
P.
• of B=-780'
CO�s E52aC 92253 .. .
;
JI BI'• ADDRESS/SPACE _uerta
COMMUNITY/STATE/ZIP (A 92253
BOK
PAG
PRC
C
.TNM
291,20
RNG
SE'/,
S.
'Y496;.;2
LOT A
j�S
Plumbing Fee ”
MOD
SEI
4
TRACT NAME �.
Santa lbsa Cave
OWNER NAME (L• F. MI)
. CO�NTRACTO�R-SRMN, ,AME ...i.
L{
ADDRESS-
CITY/COMMUNITY/STATE/ZIP
5 ,
5ONE=3:315 '
L133762
)
ARC/ENG FIRM NAME _
ADDRESS'
CITY/COMMUNITY/STATE/ZIP
P.aHONE N
LICNC 0USE
- -
'.
OF PERMIT
V/F/D 4ith shed Garage ` 1
BL'
ZON
FSB
-SSB-
SSB
RSB
OFC'•
' . 'ZONE ORO • �',.. '
-LOT. SZ ^
-
-END
SIDE k.
W7
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPLNRMTDATE
n lz-•28•.83
non,
S/F/D
P=y dt� to mnstnict 2,3 26 Sq. Ft, of S/F/D t�
with Attached Garage
Medianial Pee ;= :5-0 $:
26,00
'Plan.' (berk Fee a
291,20
Cmwtnzctian Fee 2,2.S/ G
448.00
Electrical Fee
36:90
SM Fee
Plumbing Fee ”
.739,00
Property Devealopmaht Fe~ ' .
4
City ,®l a Quints TEFF •.
a' „332.49
�' 'r•-4- YV #;r'�' '.f ��,- �at� BLDG. DEPT. r 5�,., Ex• vt�
I
a �
.s,
VALUATION $l05 j867:60 �Wry
a
Ak
NO.
OPERATION TATE
INSPECTOR
NO.
OP TION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS S
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
Aida
FurnaceCompart..
3
Steel
-35
I
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
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A 'Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb S
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
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ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring _
29A Grounding Wire
29B Bonding
30 Fixtures
31 ,Service
32 Final