0532 (SFD)-PERMIT APPLICATION
City of La Duinta
0. 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: 1 hereby affirm that I am licensed under provisions of. Chapter 9
the permit is for one.hundred ($1100)7o, less. I certify that in the,performance of the work for which this permit -is
'(commencing with Section 7000) of Division 3 o the Business andProfessionsCode, and my license is in full force .:a
issued, I shall not employ.any person inany manner so asto become subject to the Workers: Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
DateContractor
:NOTICE TO APPLICANT: If, after making this Certificate: of Exemption, you should.become subject to the Workers'
way Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
OWNER -BUILDER DECLARATION. Thereby"affirm that I am exempt from the Contractor's'License Law for the . r.+ : .. . .
be deeihed revoked.
following reason (Sec: 7031.5. Business and Professions Code: Any city'or county which requires a permit to ....
TA `40-3
construct, alter, improve, -demolish, or repair any structure, prior -to its issuance, also requires the applicantdor, ._'
; DIVIS109'6F.lNDUSTRIAL SAFETY PERMIT CERTIFICATION:
'suchpermittofileasignedstatement:thatheislicensedpursuanttotheprovisionsoftheContractor'sLicenseLaw
0'l hereby certify that nobxcavation five (5) or more feet in depthinto Which aperson is required to descend,will be
(Chapter 9(commencing with section 7000) 0Division 3 of4he Business and ProtessionsCode).or that he is exempt .
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.fi; l'
demolition'or disrriadtling thereof, will be more than.thirty-six (36).feet high: (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8, -
subjects the appticant,to a civil penalty of not more than five hundred dollars ($500.): . ' 4-r1r;Z.
C.A.C.)
0 I, as owner -of the;property, or my employees with wages as their sole.compensation, will do the work; and the
0 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 person' has a permit to do such work from that -division:
Law does not apply to an owner of property who builds, or improves thereon, acid who does such work himself orM
ARC/ENG FIRM NAME -
Y^ through his own employees, provided.that such improvements are not intended or offered for sale. If, however, the
O, Division,of Industrial Safety Permit No.
building orimprovemntissold within one year ofcompletion, the owner -builder will have the burden of provingthat
Date' Applicant
hedid not build or improve for the purpose of sale.). _ .
x ''
CONSTRUCTION LENDING AGENCY: I hereby affirm that 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. 3097; Civ..C!). i
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
Lender's Name
builifs or improves thereon, and who contracts for such projects with a contractor(s)licensed'pursuant to the..
� -
Contractor's License Law.).
Lender:s.Address
•0.1 am exempt under Sec. B. & P.C. (Attached Certificate).
I certify that I 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 .
-ZONE ORD • -
of this county to enter upon the above-mentioned property for inspection purposes. . . -
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora '
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 1 have read this application and state that
0 Certified copy: is hereby furnished.. y
the information given is correct. I,agree to comply.with all state laws and county ordinances relating to buidling
❑ Certified copy'is filed with the City Building Inspection Departm nt.or City_ • ; Deparlment.
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construction;rand authorize a representative of the City of La Duinta Department of Building and Safety to enter
upon the pro perty.for which I have applied for this permit for the purpose of making inspections.
Date Applicant
Signature of Applicant or Agent Date
AF,',P,,IC ZT NAM
,li�F 's
A4vIuSN. Tustin Av+exite, Suite 231
Cr•TJGiXYY.CR COMMUNITY/STATE/ZIP
M 92705 .
JOB'S E ADDRESS/,SPACE
.LV 7 It OCI I Juc U i�.ix iL i<iV
cIYTr/c uuIJ�"IIiiA;E/zIP� 92253
L1PRC
BOK
PAG
$ 189.00'
C
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TWN
RNG
SE
S
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a
Plumbing Fee
56.00•
0
SB.
y -
TRN T
J.t%'g�wra De La Paz,, Ltd., . .
OWN MEa, (.L�, FZCM oVe . .
CONTRACTOR -FIRM NAME
ADDRESS .
CITY/COMMUNITY/STATE/ZIP -
PHONE
O 558•-3766
`I°"° "
ARC/ENG FIRM NAME -
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N •.
LICNC 0
USEPFPL) IT�V�f /.i4dL4LlL1•M�� .
ZON
FSB
SSB
SSB
RSB
OFC
-ZONE ORD • -
LOT SZ,
_
END .
SIDE'
Print Applicant/Agent Name
APPL/PRMT i { S� �l 14-22% e84
CMdo
Permt to aanstrsct 1,704 Sq. Ft; of S/F/D
with 400 Sq. Ft. of Garage Pet aAP'Plarls
Pchaiii,ral Fee
$ 189.00'
Plan Check Fee
Paid -
Cbristructim Fee.
418.30
aectr3,foal ,Fee
32,30
SMI Fee
611162''
Plumbing Fee
56.00•
Prgxr, ty Develapnent Fee
480.00
RECEIVE®
FEB 0
City w iii i•0�...:,.
i
_ TOTAL ' .
FEE
SS yYi �� •.
BLDG.DEPT.
VALUATIONI$ 94,670.40
A
NO.
OPERATION ATE
INSPECTOR '`
NO.
OPE ATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
_ _
G
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.
❑
OPO'N
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE. & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R.
Value
•
7A Walls (Batts)
126 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 S+�' %—
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL Pi
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance •
29 Wiring o
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final9-1-2.T