0516 (SATT)PERMIT APPLICATION
City of La Dug a •
- Department of Building and Safety
This permit becomes.void if work not commenced within 180.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 it
LICENSED CONTRACTORS DECLARATION: I hereby affirm that .l 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 full force issued, I shall not employ any person in any manper so as to become subject to Workers'Compensation Laws of
and effect. California.
License Class Lic. Number
Date " Contractor -
OWNER -BUILDER DECLARATION: I hereby affirm that`bam 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 applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($50D.):
0 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 -
buildingorimprgvemntissoldwithinoneyearofcompletion, the owner-builderwilthave the burden of proving that
he did not build or.improve for the purpose of sale.)..
0 1, as owner of the property, am-excuIsiveIy 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 J am exempt under Sec. B. 8 P:C. (Attached Certificate).
Date Owner'
WORKERS' COMPENSATION DECLARATION: I hereby affirm that.l 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. -
0 Certified copy is filed with the City Building Inspecttion•Departmen I or,City, Department.'
Date Applicant ..
APPLICANT NAMEI_ MI)
"quiff N. Tustin Avenue, Suite 231
CI. c-111111 MTMUNIT- Uk 92205 '
JOB-S)jVADORES&SPACE
Jt. I 'if X°.i' IMI to Nopa1 Q, �l
CITY./COMMUNITY/STATE/ZI
4d �Lrxn�� r CPA 92253 -
BOK
PAG
PRC
C
$ 18,00
T"
FIND
SE
S
TRACT
LOT'
J
all Fee
6.20
�[(
51.00
Property Dievelopment Fee
TRACT NAME
x 19 A De Ia Paz, Ltd.
OWNER NAME M� F,.MI-., I am ,
wG
CONTRACTOR -FIRM NAME .. .
ADDRESS
CITY/COMMUNITY/STATE/ZIP .. '
P WOY.E..-3 558—
LICNC
$ 955.96
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE I
LICNC
USE01 Yj 'MI T``C=x1om.rUnW
BL
I
I ZON
FSB
SSSS
SSB
RSB
OFC
ZONE ORD I
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.Codevyou must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
0 I 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 thereoV*will be more than thirty-six (36) feet high. (Chap'3.2, Grp 2, Art 2, Sec341, Tille8;
C.A.C.) -
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.
0 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 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 thisapplication 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 permitfor the purpose of making inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
•APPUPRMT n s i s 1"11ATE-84
Permit to crostruct 10581 Sq. Ft. of S/F/D
and 400 Sq. Ft, of Garage as per applroved
P�
1�iect3ani,ozLl. Fee
$ 18,00
Plan Check Fee
Paid
Oonstructicn Fee
400.00
Electrical. Fee,
30:76
all Fee
6.20
Plumbing Fee
51.00
Property Dievelopment Fee
450,00
-FES 6 X983
TOTAL
FEE
$ 955.96
BLDG. DEPT. VALUATION $88,200.60
A
NO.
OPERATION ATE
INSPECTOR
NO.
OFWATION I 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
f=ireplace T.O.
❑
OP'N
NO.
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 I 1/ — t -- �� L
16 Water Piping
17 Rough Plumb vim
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 P1
STREET NAME
26 Power Pole
27 Conduit �►
28 Service Entrance "
%67-
29 Wiring
29A Grounding Wire _ T�
29B Bonding
30 Fixtures
31 Service -
32 Final / �1