001046 (SFD)PERMIT APPLICATION
City of La Duinta
• - Department of Building and Safety •
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.
0 I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
structure isnot 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.
throLgh his own employees, provided that such improvements are not intended or offered for sale. If, however; the
building orimprovemntissoldwithin one year ofcompletion, the owner -builder will have the burden of proving that .
he did not build or improve for the purpose.of sale.).
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
Contractor's License Law.).
0 1. am exempt under Sec. B. 8 P.C. (Attached Certificate). :t=
Date '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. 3800..Lab. C.).
Policy No. Company -
0 Certified copy is hereby furnished. a
0 Certified copy is filed with the City Building'lnspection Department or City' Department. -
Date Applicant
.APPLICANT NAME b.. MM.lt_Ohrom
•• . •
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. I 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 futl.force -
issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of
and effect.
California.
Liceme Class Lic.Nutmber
Date Applicant
l
Date Contractor / - -� — /- -
NOTICE TO APPLICANT' If, after making this Certificati of Exemption, you should become subject to the Workers',
OWNER -BUILDER DECLARATION: I hereby affirm that I m exempt tram the Contractor's License Law for the
CoInpensatiamprovIsions 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 deemedrevoked.
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permil4o file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
01 hereby certify that no excavation five (5) o.r more feet in depth into which a person is required todescend. will be.
(Chapter 9(commencing with section 7000) of Division 3 o1 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 permit
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec341, Tille8,
subjects the applicant to a civil penalty of not more than five hundred -dollars ($500.): -
C.A.C.)
0 I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
structure isnot 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.
throLgh his own employees, provided that such improvements are not intended or offered for sale. If, however; the
building orimprovemntissoldwithin one year ofcompletion, the owner -builder will have the burden of proving that .
he did not build or improve for the purpose.of sale.).
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
Contractor's License Law.).
0 1. am exempt under Sec. B. 8 P.C. (Attached Certificate). :t=
Date '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. 3800..Lab. C.).
Policy No. Company -
0 Certified copy is hereby furnished. a
0 Certified copy is filed with the City Building'lnspection Department or City' Department. -
Date Applicant
.APPLICANT NAME b.. MM.lt_Ohrom
ADDRESS 400 N. Tustin Ave. Suite 231
CITY/COMMUNITY/STATE/ZIP
Santa Ana, CA 92705
JOB SITE ADDRESS/SPACE ` j f In A]/{ Ji/✓ J4 /j . . O�^�
~hTY/ K
. CITY/COMMUNITY/STATE/LIP '
La Quinta, CA' 92253
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61"
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13640-3
LOT
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TRACT NAME •�'��„a }}••������ TT,�� �^ '
f�L� D ' La Paz
OWNER NAME (aL. F. MI) t _
r
CONTRACTOR -FIRM NAME t , ..
M"CyC'1�M:Y••Ir{•7•v1.1
ADDRESS '
abouts
CITY/COMMUNITY/STATE/ZIP �.
above
PHONE 1 '.LICNC
/
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC 1
USE OF PERMIT T1
S.F.D.
BL
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END
SIDE ,
0 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.
O.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
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
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and'statethat
the information given is correct. I agree t ,comply with,all tate laws and county ordinances relating to buidling
construcfibnd and authprize a�represe ative,of the City`L Duinta Department of Building and Safety to•enter
Upon he pr perty for which . ave applied for this per iit for the purpose of.making inspections..
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT Rn fl DATE
U-19-84 S.F.B.
Ptezmit to add addi tiLona12 26 sq. ft.
Refer back to original penniit #0518
Previous bedrom aloes not conform as
bed== as per UBC Egress & Regress
requirements. At notime can this
room be used as a bedroom.
RECEIVED
-NOV 2 9 1984
INI 11
BUILDIN DFP RTMFNt
" TOTAL '.
FEE
—0—
BLDG. DEPT.
VALUATION —o—
NO.
OPERATION DATE
INSPECTOR
NO.
O ATION 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
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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
PSL P)
STREET NAME
26 Power Pole
27 Conduit
28 'Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final