0165 (SFD)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety
�V
6�v2 Y,18
This permit becomes void if work not commenced within 180 days from date of issuance, OR, if work has been suspended or abandc'led for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
and effect.
License Class
Date Contractor
Lic. Number
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) orthat 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.):
❑ I, 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, add 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 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.).
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
7044. Business and Professions Cade: 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.).
❑ 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. Q.
Policy No. Company
DeCertified copy is here furnished. ,�
❑ Certified copy is filed with theiCitj Building Inspection Deepartmlen'� ot'City In Department.
Date d Applicant iO
7f
APPLICAAMENT pint venture
ADDRESS
V # V. Bon 7�J80
CITY/COMMUNITY/STATVZI P
La ilu�lnta, Ca 92253
JOB :�l:s"Tt�ti4ADDREsiwenidEa Vista Vonita
CITY/COMMUNITY/STATE/ZIP s
La vuinlra, c a 9224,3
BOK
PAG
PRC
I C
Patio Cover
TWN
I RNG
SE
S
R�
17
1171
31.25
Plumbing Fee
MO—
1
SB
209.00
TRACT NAME
_,Onx:u.ioriL1 COVO
OWNER NAME (L. F. MI)
IiJl1; y'FICUIPotratiOlt
ADDESS
P.Q. Box 780
'%/° >zitu s Ca 92253
CIS-, 5C4-1315
E CEIVED
LI3°33762.
ty01 _ Quinta
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP .
PHONE N
LICNC N
,USE ill PEfjM�T I
6welling
dZON
BL
I"&mily
FSB
SSB
SSe I
RSB
OFC
ZONE ORD N
LOT SZ
END
SIDE
. CERTIFICATE OF EXEMPTION FROM WORKERS' OMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
issued, I shall not.employ any person in any mamer so as to become subject to the Workers' Compensation Laws of
California.
Date Appliont
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 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 WE permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more Van thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8.
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 Jerson has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
Applic: nt
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec 3097, Civ. C.).
Lender's Name
Lender's Addre
I certify that I have read this application and staE that the above information is correct. I agree to comply with all
city and county ordinances and state laws relatirg'to building construction, and hereby authorize representatives
of this county to enter upon the above -n entiond property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE ANDA THORIZATDN OFENTRY: Icert'1yl have read
the informatiop given is:correct.4agree to comp^d with all state laws and county ordinances relating to buidling
construction, andaauthorize-a )epresentative of -he City of La Ouinta Department of Building and Safety to enter
upon thejp�pe �ty fo�'I wtiiaONapp'liedfor tais=permit for the purpose of,making i s`576ion r
VV Sign tyre of A� Icant;orAgent Date
' , �- d,.i r� .�
Print Applicant/Agent Name
APPUPRMT f+,I"
.jy d •a'a
DATE.
!S �' l G
Permit to cr nat:ruct Model 2-3wT?
Dwelling
1,616 sq. Pt,
C'ue€3t Room
277 SCj. yet.
Garage
MIN "q. Ft.
Patio Cover
140 J' a. irt:.
Nech. Poe
$ 3:1..00
, lecEric Fee
31.25
Plumbing Fee
52.50
Flan Check Fee
209.00
Building roe
124.62
Property Deno
Foe 450.00
E CEIVED
yr"�
ty01 _ Quinta
TOTAL].
FEE
$ . 3'
VALUATION $94 � 517. �0
Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept.
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALSMECHANICAL
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
r�t�%
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.
❑
OWN ADDITIONAL INFORMATION
NO.
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick
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 PiI
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire " Y '' "' ° •':i{
29B Bonding .
30 Fixtures
31 Service
32 Final