0525 (SFD)PERMIT APPLICATION
• City of La Dg 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. "
CITY/COMMUNITY/STATP/Z P
92253,
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 full 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.
License Class Lic. Number
Date 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
be deemed revoked.
• following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
Se
' 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 to,file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
] I hereby certify that no excavation five IS) or more feet in depth into which a person is required to descend, will be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) or that heis 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-siz (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title B,
• subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): -
CAC.)
O Las owner -of the.property, or my employees with wages as their sole compensation', will do the work, and the
O As owner -builder, I will not employ anyone to do work which -would require a permit from the Division of
structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person has 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 w
LICNC .
through his own employees, provided that such improvements are not intended or offered for sale. If, however: the
0 Division of Industrial Safety Permit No.
building orimprovemntissold within one year.of,completion. the owner -builder will have the burden of proving that
Date- Applicant
' he did not build or improve for the purpose of.sale.):
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance .
❑ I: as owner of the property, am exculsively contracting with,licensed contractors to construct the projecb(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 -
OFC "
Contractor's License law.).
Lender's Address
O 1 am exempt under Sec. B. & P.C. (Attached Certificate).
I.cenify that I have read this application and state that the above information is correct. I agree to comply with all
Date Owner "
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
'to.enter
END
of this cou6t upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby -affirm that I have a certificate of consent to selhinsure, or'a '
'certificate of Workers' Compensation Insurance : or'a certified copy thereof (Sec. 38OOAab. C.).
Policy No. - . Company, -
D=Certified copy is hereby furnished.
O•Certified copy is filed with the City Building lnspecti' on.Departm�r,City Department.
DateApplicant
tAP LICA T NAM_ 0.1=1
4vuE iii. Tustin Aveme, Shite 231
CIT /COMMUNITVSe TEI�,..it.. 2705'
too-ore •AODRESS/SPACE *y��t
. �.V� Lie Nopal w 8- a 5-5
Z,
CITY/COMMUNITY/STATP/Z P
92253,
BOK
PAG
'PRC
C
Mechanical Fee
TWN
RNG
SE'
S
TRACT
LOT
35.66
SNI Fee
7.60
Se
56,00
LME
;Idl x De La Paz, U-4
aGGO�W��'N,�ER NAMExIL..F,RM
rciiLflj,i
:CONTRACTOR -FIRM NAME .- -
ADORE QS
CITY/COMMUNITY/STATE/ZIP
i"�14) 5�8-3766
■\ E F
�v
LIONC .
My Zof 42
ARC/ENG FIRM NAME '
ADDRESS
CITY/COMUUN ITV/STATE/ZI P
HONE .
LICNC .
-
USE OF PERMIT
:LP
BL
ZONFSB
SS8
SSB
RSB
OFC "
ZONE ORD N
LOT SZ
END
. SIDE,
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.] 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 permit for the purpose of making inspections. '
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT r.�%IDANE�84
.
Permit to construct 1,973 Sq. Ft.
of S/F/D
with 400 Sq. Ft. of Garage per approved
n1an-s
Mechanical Fee
$ 18,00
Platt Check Fee
_aid
cmukruction Fee
455.50
Electrical Fee
35.66
SNI Fee
7.60
Plumbing Fee . I
56,00
p rtmpe t , DeveloFme t Fee
450.00
■\ E F
�v
4149
My Zof 42
^
TOTAL
FEE
,Ue: G. /Eq
• • �7UL'U+Ki,�ii.Jai�U'
VALUATION
`n BLDG. DEPT. -
A Ah
NO.
OPERATION ATE
INSPECTOR,
NO.
i' OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
Art
2
Ftgs & Frms
- -
r
34
-
Plenums:4 Ducts
2A
'Slab Grade
35
Furnace Compak.
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 5�GS.$�
10A
fireplace T.O.
❑
OP'N
NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE &LOCATION
11 Exterior Lath IL
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick Value
7A Walls (Batts)
12B Ceiling (Batts)
126 Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping CO
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
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