0514 (SFD)' PERMIT APPLICATION
' City of La
Ouinta
' Department of Building and Safety
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This permit becomes void if work not commenced within':180 days from;date of.isauance;
OR„if work has been•suspended.or abandoned fora period of 180 days. I
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need'not be completed if
'.,.LICENSED CONTRACTORSDECLARATION:. 1. hereby affirm, thatam licensed under -provisions. of Chapter 9 .'-
the.permit is for one hundred ($100) o, less. I certify,thal 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 asto become subject to the Workers' Compensation Laws of.
,and effect.
California.
TLicense Class ` Lic. Number
Date Applicant;
Date ' - Contractors- - r
5
NOTICE TO APPLICANT If, after making this.Certificate,of Exemption,you should become subject to the Workers
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OWNER -BUILDER DECLARATION: f hereby affirm that.l am exempt from the Contractor's License Law for the '
.Compensation provisions of the Labor Code, you.mustforthwith 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 . ,
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r construct; alter:improve>demolish, or repair'any structure, prior to its issuance, also requires the applicant for.
DIVISION OF INDUSTRIAL SAFETY PERMIT -CERTIFICATION: '..t.
_suchpermit.tofile,asignedstatementthatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw..
.: 0 1 hereby cirtily that no eicavation five (5).or more feet in depth into which a fierson is required to tiescena, will be .
” (Chapter 9(commencing with section 7000) of Division3of 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
r therefrom and the basis for the alleged exemption ,Any vfolatiop.of Section 7031.5 by any applicant for a permit ,
- • 'demolition or dismantling thereof, will be more than thirty- six .(36) feefhigh. (Chap 3.2. Grp 2, Art 2, Sec 341; Title 8;
subjects the applicant to a civil penalty of not more:than live hundred dollars ($500.):
C.A.C.)
as owner of the property, or my employees with wages as their sole compensation, will do the work, and the -.p'As
ownerbuilder, I will not employ anyone to do work which would -require a permit from the Division of
structure is hot intended or offered for. sate. fSec. 7044; Business and, Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person-haa 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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through his ownemployees: provided that such improvements are not intended or offered for sale..lt; however, the
0 Division of Ind strial Safety Permit No.
@ .. .. .. ,
building orimprovemntissoldwithinoneyearofcompletion,theowner- builder will have the burden of proving that
.Date' Applicant
hedid not build or improve for the purpose of sale.). . " •
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CONSTRUCTION'LENDING AGENCY: I hereby affirm that there 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
builds or'improves thereon: and.who'contracls for -such projects with a contractor(s) licensed.pursuant to the ..
:. Lender's Name
Contractor's License Law.). ice-
Lender's Address
•' 0 lam exempt under Sec: '' Br8 P.C. (Attached;Certificate)..
I certify that 1 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:' -
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: .1 hereby affirm that I hive a certificate of consent to self -insure, or. a
' certificate of Workers, Compensation Insurance , or a certified copy thereof -(Sec: 3800. Lab: C.). : s
Signature of Applicant or Agent :*� Date
Policy. No. Company, �L
CERTIFICATE OF COMPLIANCE ANDAUTHORIZATION OF ENTRY: I certify I haveread this application and statethat -
❑ Certified,copy is .hereby furnished: V
'the information given is correct. I agree to comply with all state laws and county ordinancesrelating to buidling '
' O Certified copy is filed with the City. Building Inspection Department.or City- Department
-construction, and authorize a representative of.lhe City of La Ouinta.Department of Building and Safety. to enter
Date Applicant
upon the property for.wfiich I:have applied for this permit for.the purpose of making inspections, ,.
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Signature of Applicant or Agent Date
Print, Applicant/Agent Name y' r
APPLICANT NAME IL,F, MI)
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"°°;5" sN; Tk1Stin'AverMe; Suiibe 231
+CITY/COMMUNITY/ST.ATE/ZIP -
r.7(.4N&& :iurus . EA 92705.
Jy 144 `A1rODRE PA"aNopal
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32030' •-
SMI Fee
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SB.
:' 56,00; ,
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CONTRACTOR -FIRM NAME
ADDRESS , • .. . ,. -
CITY/COMMUNITY/STATE/ZIP .+„ ..... . • „
PHONE �.4) .SSS -3766
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ARC/ENGFIRM NAME
ADDRESS -
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APPUPgMT
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Pennit to c6nstruct,1 '704 Sq,
Ft.' of 5/:°/D
with 400. Sq. Ft. of Garage as per approved
nAans
Elm
S -1800'.
Plan check Fee
Ccinst;ructich-Fee, Fee'
•'',418400
Electrical Fee
32030' •-
SMI Fee
Plimhin4 Fde
:' 56,00; ,
Property Development Fee
450;00:'
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• :hog. I.:111,1..
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BLDG. DEPT.,
VALUATION j670.40
NO.
OPERATION ATE
INSPECTOR:t4,:
,
NO.
. OPERATION DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
Y&
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
-.2—_,Ff—
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.
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ADDITIONAL INFORMATION
64 `V
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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 ep/
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
STREET NAME
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26 Power Pole
27 Conduit
28 •Secvice:Entrarice";,..:.
29 Wiring
29A Grounding Wire
29B Bonding
30 , Fixtures
31 Service
32 Final