0423 (SFD)APPLICANT NAME . F. M
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;EAIT APPLICATION
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City of La Ouinla
Departi4ent of Building and Safetj.!
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PAG
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1 This permit becomes -void if work not commenced within 180 days from date of
issuance. OR, if work has been suspended or. abandoned for :, period.of'180 days'
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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 (SIOO) o, less. I certify.tha: in the performance'of the work for which this permit is
(commencing with Section 7000).of Division Sof the Business and Professions Code, and my license is in full force
issued. I shall not employ any pe(son inany mannersoaE to become subject to the Workers'Compensation Laws of .11
effect.
California.and
License Class Lic. Number
Date Applicant.
Date Contractor NOTICE TO APPLICANT: If; after making this CertificitiA Exernotion, you should become subject to the Workers'
in -�m exempt from -the Contractor's Lice se aw'. ' ' '
OWNER -BUILDER DECLARATION: 'I hereby'affir that i License L " for the
e, Compensation provisions of the Labor Code, you must firthwit comply with such provisions or. this permit shall
. . . P, 0
It e deem id fe�oked!
following reasoh'(Sec. 7031.5. Business and Professions. Code: Any city or county which requires a permit to
, i
construct, alter, improve.: demolish, or repair any structure; prior to i%6 issuance, also requires the•applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT.CERTIFICAT'lf,N:
such permit to fi fe a sig qed statement that he is licensed pursuant to the provisions of the. Contractor's Licen, se Law
01 hereby 6rtify thai no excavation H4(5) or rn�ore feetn depth into which alpersori is required to descend, will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that 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,pprmit
derrolitiori or dismii intlinj thereof. will be'more thah thirty-six (36) feel high. (Chap 3.2. Gip Z Art 2. Sec341, Title8:
subjects the applicant to a civil penalty of not more than live hundred dollars ($MO.):
C.A.C.)
0 I. as owner of the property, or my employees with wages as theirsole-compensation, will do the work, and the
0 As owner-buildeir, I will not employ anyone to do work which would require a permit'from the Division Onof
structure is not intended orsoffered for sale (Sec. 7044, Business and Professions Code:.The Contractor's License
lndu§trial Safety, as noted above, unless such person las a-perTit to do such work,from,that division.,-
. .
.,'.Law does not apply to an owner of property who builds, or improves thereon, and who does such work.himself or
- .; , . I . .
through his own'employees, provided that such improvementsare not'intended or offered for sale. It, howeverAhe
0 Division of Industrial Safety -Permit No:
building.or.improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that.
Date Applicant
he did, build or improve for the purpose of sale.)..�-,- - , .: � .- .. , .. . : y - . . "
• ..
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CONSTRUCTION LENDING AGENCY:, I hereby affirm that there Is a construction lending agency for the performance —7
0 Las owner of the property. am exculsively contracting with,licensed contractors to construct the project (Sec:
of'the WOW for which this opermitAs issued' (Sec. 3097, 'iv. C.).. -
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
Lenders Name
builds or improves'thereon, and'who contracts for such projects* with a cont6clor(s)'licensed pursuant to the
Contractor's License Law.).
Lender's Address -
,0 1 am exempt under Sec. '_B.$ P.C., (Attached Certificate):
I certify that I'have read this application,and state that t3le above information is correct. I,agree to comply with.all
✓-city,and
Date Owner
county ordinances and state laws relating to bulding construction, and hereby authorize xepresentatives"
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a Certificate -of consent to self -insure, or'a
certificate of Workers' Compensation Insurance , of a certified copy thereof (Sec. 38010i Lab: C.)., -. .- - : ' - ".
Workers' _ .
•. . . T ' Signatulie of Applicant or Agent Date
No Company many
Policy p
. I . . . .- . - .. . . I.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I �a4e read this application and Mate that
0 Certified copy is hereby furnished.. 4
nDepaArt
lKe,information given is correct. I agree to comply with state laws and county ordinances relating to buidling s,"
'Zity Bu Department
ildifig.Inspection' Department.. -11Y
Certifidd.cbpy':i ilelvifthrite t.. C.,
96/V.
construction, and authorize a representative. of the Cit- of LaQuinta Department of Building arid Safety to enter
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upon the property for -which I have applied for this permit for the purpose of making inspections t-
Vow 0 A-pplicant
.
Signature of Applicant or Agent Date
APPLICANT NAME . F. M
15� imtim
ADDRESS f r
P, 01 B= 780
CITY/COM MU14ITY/STATE/Zip
Ia Qt�ta # (M 92253
J.QPATE ADDRI SSISPACE -
_14A la Aiert;a
CITYICOMMU14ITY/STATE/ZIP
la Quanta, Ch 92253
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TRACT NAME
Santa I;bsa Oom
OWNER NAME (L. F. MI)
CONTRACTOWFIRM NAME
Sme As Abom
ADDRESS
CITY/COMMUNITY/STATE/ZIP
,PHONE a
564-131.5
LICNC
333762
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE#
-ULU 49 9830
City.® La Quintar
*ICNC 0
USE OF PERMIT
S/F/D witki Attached Garage
131.
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END
SIDE
Print Applicant/Agent Name
-APPUPRMTn
-423
0
DATE
'U-28-83�
S/VD,
Penut to cionstruct 20758 Sq. Ft, of S/r/D
with Attached Gat'
$:
'Plan'tcheck Fee
-326.95
'C>
-3 5030"00
Flee
a 8
`42#16'
SMI F
8""g's.
Pluirbing Fee''.
73900-
Deve.1.6prIent Fee h,
450,00
-ULU 49 9830
City.® La Quintar
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FEE
$'4b0;,04-`_
BLDG. DEPT.
VALUATION1$121,6
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is
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NO.
OPERATION MTE
INSPECTOR
NO.
OP TION 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
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
t2 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
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
PI 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