001021 (SFD)PERMIT APPLICATION
r City of La Ouinta
• 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 or a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division Sof the Business and Professions Code, and my license is in full force
and effect.
License Class Lic.Num�-
Date �� �-j �Contractor, l -�
1
OWNER -BUILDER DECLARATION: I hereby affirm that I am exemptVm 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 ($500.):
O 1. 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. It, however, the
building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that
he did not build or improve for the purpose of sale.).
O 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.
Date Owner
B. 8 P.C. (Attached Certificate).
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
O Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. M7II��(�������� �y�.�,
t91i1 m I.RJ.GLJ.
ADDRESS
P.O. Box 780
- CITY/COMMUNITY/STATE/ZIP
La CA 92253
JOB SITE ADORESS/SPACE
49-470 Avenida Vista Boaaita
CITY/COMMUNITY/STATE/ZIP
La Oainta CA 92253
BON
PAG
PRC
C
TWN
RNG
SE
S
TRACT
1449 i2
I LOT
13
MODSB
1 Cr3
TRACT NAME
Santarcea Dove
OWNER NAME (L. F. MI) Arxkn
CONTRACTOR -FIRM NAME
Anden
ADDRESS
above
CITY/COMMUNITY/STATE/ZIP
above
PHONE •LICNC
564-1315
•
333762
ARC/ENG FIRM NAME
ADDRESS
1531 Mavala Street
CITY/COMMUNITY/STATE/ZIP
Santa Barbara CA 93101
PHONE 1
LICNC •
USE OF PERMIT
simle family d ellim
BL
ZON
FSO
SSB
SSB RSB
OFC
ZONE ORD •
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMP NSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certifk that in the performance of the work for which this permit is
issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you In ist forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O 1 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 pe mit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than hirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2. Sec341, Title 8.
C.A.C.)
O As owner -builder, I will not employ anyone to to 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
Applicant
CONSTRUCTION LENDING AGENCY: I hereby affirm teat there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 31'97, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state t rat the above information is correct. I agree to comply with all
city and county ordinances and state laws relating b building construction, and hereby authorize representatives
of this county to enter upon the above-mentioned rroperty for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATIOF OF ENTRY: I certify I have read this application and statethat
the information given is correct. I agree to comply vith 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�pelty or which l have applied for thie permit for the purpose of making spect ns.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPUPRMT{� q DATE
nn 1 4- 10-22-84 S.F.D.
attached aaraae. This nexmit to
renlalne # 0419 F
Mech Fee 13.00
M -k FIl 32.05
Ormst. Fee 246.50
?0.49
34.00
i�
r r
J. gpM��l
TOTAL %
FEE -%
VALUATION —r")—
BLDG.DEPT.
r-1
A&
NO.
OPERATION ATE
INSPECTOR
NO.
OP ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
S
,
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 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/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding,
30 Fixtures
31 Service
32 Final