0428 (SATT)PERMIT APPLICATION
V , City of La Og 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 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 oto become subject tothe Workers'Compensation Laws of -
and effect. California.
License Class Lic. Number
Date' - Contractor
OWNER -BUILDER DECLARATION: I hereby affirm that I am 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.heis 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 ($500.):
O 1. as owner o1 the property.,or my employees witth.wages as their sole compensation, will do the work, and the
structure isnot intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds, or improves thereon, and who does such work himself or
through his own employees. provided that such improvements are not -intended or offered for sale. If; however, the
building ot.Ly)proverrml is sold within one year of completion, the. owner-builder.wil I have the burden of proving that ..
he did not build or improve for the purpose of sale.).
Cl. I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:
7044, Business and Professions Code: The Contractor's License Law does not apply to an -owner of property who
builds or improves thereon, and who contracts for such projects with a.contractor(s) licensed pursuant to the.
Contractor's License Law.).
O. 1 am exempt under Sec. ; .. B: 8 P.C. (Attached. Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a -
certificate of Workers' Compensation Insurance , ora: certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
❑ Certified copy is hereby, furnished.
�Q Certified -copy is -fired With t ie CltylBuilding.Inspection•'/Department'or City ' �.n Department.
� t, f Ti _ r ° J Applicant
APPL- _ ICANYNAME
_-. (L, F,
rk 1(••Y�S"'1"�[TY..11d'Gf$• j
ADDRESS '
P. 04, Bm 780
CITY/COMMUNITY/STATE/ZIP
MUNITE/zIC 92253
7lt��ADORFiSStSPACE
JOB SIT
49-•11'4 A venlda Vista Bcnita
CITY/COMMUNITY/STATE/ZIP '
la QWnta,. CA 92253
BOK
PAG
PRC
C
Plan Cheds •Fee _30-05
TV N
RNG
SE
S
TRACTLOT
14496-•2
22
Plwnbinq Fee y.00
68.00
MOD
Cr2
SB'
,
TRACT Santa How Cbm
OWNER NAME (L. F. MI) '
CONTRACTOR-FIRMAbTNAMMEE - - -
Sam As me
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
564-1315
LICNC N
333762
I .b9
LJ J
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PH�ONNEE •
#
'
y� y,�,,:,w�,,,.,� �LIICCNyC
S/ + PERMIT
Attache
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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 Code, you must forthwith comply with such provisions or this'permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATGON:
O 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 permi.;, and that no building structure, scaffolding, falsework, or
demolition or dismanfling thereof, will be more than thirty-six (36) feet high..(Chap 3.2, Grp 2, Art 2, Sec341, Title B:
C.A.C.)
O 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 persor has a permit to do such work from that division.- -
O Division of Industrial'Safety. Permit Nd
Date Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm iha: there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 309-. Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state tha the above information is correct.I agree to comply with all
city and county ordinances and state laws relating to ruilding construction, and hereby authorize representatives
of this county to enter upon the above-mentioned pr perty for inspection purposes. -
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION CIF ENTRY: I certify I have read this application and state that.
the information given is correct. I agree to comply w;h 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-
APPUPRMT n Jfp R DATE
12,;-28.82
S/F/D
Permit to clmstruct 28651 Sq. Ft. of S/F/D
with Attached Garage
2iaaical Fee $
'26.00
Plan Cheds •Fee _30-05
320.45
Canstructim Fee �y�o-sO 493.00
Electrical. Fee ao . 4 �1
40.97
SMI Flee
8„65
Plwnbinq Fee y.00
68.00
P=perty Wml o meat Fee
450.00
A
R E C E R V E 0
I ' r
^
IA22
I .b9
LJ J
�Co,
TOTAL
FEE
$ 1,,407.07
BLDG. DEPT.
VALUATION $123,178.60 '
r_l
Ah C-__ _.
NO.
OPERATION ATE
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 File Wall*"'
42
Commercial Hood
10
Fireplace P.L.- 0
43
Final
10A
fireplace •T.O.. • ❑.
NON
ADDITIONAL INFORMATION
i
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
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/l
STREET NAME.
26 Power Pole
27 Conduit
28 Service Entrance
29. Wiring
29A Grounding Wird,
29B Bonding
30 Fixtures
31 Service ;e%`
32- Final �4 rC•