0417 (SATT)PERMIT APPLICATION
City of
La
Dg
b�ta
Department of Building
and Safety -
a
This permit becomes void if work not commenced within 180 days from date of
issuance, OR, if work has been suspended or abandoner for a period'of 180 days.
,PAG -
CERTIFICATE OF EXEMPTION FROM WORKERS' COM°ENSATION INSURANCE: This section need not be completed it
LICENSED CONTRACTORS DECLARATION: thereby affirm that r am licensed under provisions of Chapter 9
the permit is forgone hundred ($100) o, less. I certiy that in the performance of the work for which this permit is
(commencing with Section 7000) of -Division Sof the Business and Professions Code, and my license is in full force*
issued, I shall notemploy any person inany manner soasto become subjectto the Workers'Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applican-
Date • Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subjectto,the Workers"
OWNER -BUILDER DECLAf{ATION:I hereby affirm That I am exempt from the Contractor's License Law for the
Compensation. provisions of the Labor Code, you crust forthwith comply with such provisions or this'permitshall:s.
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit. to
be deemed revoked.
construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFI:ATION: .
such permit to Idea signed statement thathe is licenSed,pursuant to the provisions of the Contra.ctor's License Law
0 1 hereby certify that no excavation five (5) or mor- feet in depth into which a person is required to descend, w it I be
(Chapter 9(cammencing with section 7000) of Division 3 of the Business and Professions Code) or that heisexempt
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 thar thirty-six (36) feet high. (Chap 3.2, Grp 2, Arlt, Sec 341, Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):I
C.A.C.)-
0.1, as owner of the property. or my employees with wages as their sole compensation, will do the work,11,the -
t 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 peron has a permit to do such work from that division.
Law does not apply to awowner of property who builds, or improves thereon, and who does such work.himseltor
usSIF7L) with Attached GaZ3ge
through his own employees, provided that such improvements are not intended or offered for sale. lf, howeverNhe
0 Division of Industrial Safety.Permit No.
building or improvemnt is sold within one year of completion, the owner -builder will hay.etheburdenofprovingthat
Date Applicang
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm mat there is a construction lending agency for the performance
0 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. 3397, Civ. C.).-
.).7044.
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
ZONE ORD N.
Contractor's License Law.).
Lender's Address „
' 0 1 am exempt under Sec.' B. 8 P.C. (Attached Certificate).
I certify that I have read this application and state eat the above information is correct. I agree to comply with all
*Date Owner
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.
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.).
Signature of Applicant or Agent Date
Policy No. Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
0 Certified copy is hereby furnished.:. • /}
1
or
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
Certified copy is -filed with,the4ity Building Inspection Department City ; Department.:
/ / •�. (/,--=.--- °
'Date
upon the property for which I have applied for this permit for the purpose of making inspections.
Applicant
_.
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPLICANT NAME,(L F; MI)
[i t.t�riratlal
ADDRESS
.C). BoK 780 ..
CIT9Yi _ NITY/SrTAaT�ZIP.w 9,.2,. -53
(,L7�
�/COMMU-
�M,"�+w
JOB)SI JVLJI t'l 1ADORPV a Ban iha
CITY/COUMUMTYlS. TI�,T� zI 92253
1. �.CPPRC
BOK
,PAG -
C
26.00
TWN
PING
'SE
S
TRX4T49M�E�A
L
S -TE Fee '
8,93
Plumbing Fee
SB
Property Dmvlapnent,F�:
W�OT.,�
TFINA Y Ric sa .
/�Ve
OWNER NAME (L. F. MI) '
CONTRr�AC OR -FIR NAM -
"x ratitCt! .
ADDRESS
P.Baas 780 .
CIT OMMUNIy Yyy�TY/ST�ATi8ZICA 92253
PH564-1315
-
`I_333762
ARCD/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
-
LICNC N
usSIF7L) with Attached GaZ3ge
81.
ZON
FSB
SS8
SS8
RSB
OFC
'
ZONE ORD N.
LOT SZ
END
SIDE
APPVPRMTn41 7 , ^DA
`TE,e_83
S/F.,ill"D '
Permit to conatnict 2,,758 Sq. Ft.
of S/V/D
with Attached Garage
Mchani;cal Fee - $
26.00
Plan Che& Fie
326.95
CcnstructicIn Fee
503.00
Electrical Fee
42.16
S -TE Fee '
8,93
Plumbing Fee
73.00
Property Dmvlapnent,F�:
450.00
E8
TFEE
$ 1,430.04
BLDG.
VALUATION $127,658.80•
DEPT.
r 1
-E
NO.
OPERATION I TATE
INSPECTOR
NO.
OP ATION 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
fireplace T.O.
NPON
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
-
P/L P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 FiztuYes"
�.
31 Service
32 K l' �`.•