0586 (MECH)PERMIT APPLICATION
City of
La Ouinta' --
Department of Building and Safety
This permit becomes void if work.notcommenced within .180 days from dale•of'issuance,
OR; if work•has been suspended or.abandoned fora 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 underprovisions 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•mylicense is in full force
-issued,. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
and effect.
California.
License Class Lic: Number
Date Applicant
Date` ' `'- Contractor ' ' -
NOTICE TO APPLICANT: If, -.after making this Certificate of Exemption,.you should become subject to the Workers`
OWNER -BUILDER DECLARATION: I'hereby affirm. that I am exempt from the Contractor's'License Law for the ':
Compensation provisions - of the. Labor Code, you must forthwith comply with such provisions or this permit shall
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.
DIVISIOfV.OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statementthat he is licensed pursuant to theprovisions of the Contractor's License Law
'01 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
(Chapter 9(commencing with section.7000) of Division 3 of the,Business and Professions Code)06hathe is exempt, ... .
made in connection With work authorized by this'permit, andthat no'building structure, scaffolding..falsework, or
.. therefrom and the basis for the alleged exemption. Any violation of Section, 703 ' 1.5 by; any. applicant.for a permit..
demolition or dismantling' thereof: will be more than thirty-six.(36)4eet high. (Chap 3.2; Grp 2, Art 2, Sec341, Title B..
subjects the applicant to a civil penalty of not more than five hundred dollars $500.): rr`"i -
C.A.C.)
O 1. as owner of the property, or my employees with, wages as their sole compensation, will do the work, and the
❑ 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, and who does such work himself or
o-
through his'own employees; provided that such improvements are not intended or offered for sale: If, however, the
❑ Division of Industrial Safety.Permit No.
building or improvemnt issoldwithin oneyearof completion; the ownerbuilder will have the burden of proving that
Date Applicant
he did not buil. or improve for the purpose of sale.).
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:).
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•.
Contractor's License law.). __
Lender's Address
.O Pam exempt under Sec.' . B. 8 P.C. (Attached Certificate):,.,
I certify. lhat.l'have.read this application and state that the above information is correct:9 agree to complywith all •-,
Date " Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
-
'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•copythereof (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 thisapplicationand state that
O Certi ted copy is hereby. furnished:. :. ,
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling r
* Certilied.copy is tiled with the City Building Inspection bepartmenhor City 'Department.
construction, and authorize a:representative of the City of La Ouinta Department of Building and Safety to enter
!j y `' I •
/ 3C j Applicant `•c' ^3 [ 0�� e a -s-_-
upon the property for -which I'have applied for this permit for the purpose.ot making inspections:
Date Y
.
Signature of Applicant or Agent Date
ME
,AP z/OCANT
p�iLI�JISon1, f��RU@ Cy LLVn.ITi-I / A
ADDRESS
L/ C1 r'� �L d e�✓
CITY/COMMUNITY/STATE/ZIP
1, A J7 -A CA
JOBSIT_ E ADDRESS/SPACE �
CITY/COMMUNITY/STATE/ZIP - -
BOK
PAG
PRC
C
TWIN
FIND,
SE
S
TRACT
LOT
MOD
SB
TRACT NAME '
OWNER NAME (L. F. MI)
-->- M i
CONTRACTOR•F.IRM NAME
r0P,
ADDRESS / -
a�,v. @pox int'
�9 ft
CI,`A �M Y/STAT�fI S s /-` I
:.
'TOTAL'':
FEE
ARC/ENG FIRM NAME •.
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE •
LICNC.•
USE OF PERMIT
BC
20N
fSB
'SSB
SSB
-.RSO.
OFC
• ZONE ORD•.
LOT SZ •:
ri:�y.:.
,",END ,'
, SIDE,'
Print Applicant/Agent Name
APPL/PRMT S ID ,
_
l's,C.r3YIl
Q
.N A
:.
'TOTAL'':
FEE
!
VALUATION
o
.� BLDG. DEPT. J.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION 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.
❑
NON ADDITIONAL INFORMATION
� l
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
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PI P/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
.29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final