001159 (ELEC)PERMIT APPLICATION
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 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 rChapter 9 the permit is for one hundred ($100) o. •less. I certify that in the performance of the work iorwhich this permit is
(commencing with Section 7000) of Division 3df the Business and Professions Code, and my license is in lull force, issued, I shall not employ any person in anymannerso asto become subject tothe Workers' Compensation Laws of.
and effect. California.
License Class 1-crNumber r^� _.r •\ n Date Applicant
Date - Contractor- �f��-.t-�� l f� �'r 4`••`�� 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
OWNER -BUILDER DECLARATION: I hereby affirm'that I am exempt fiom the Contractor's License Law for the be,deemed revoked'
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 DIVISION OF INDUSTRIAL. SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
0 1 6eby certify that no excavation five (5) or more feet in depth into which a person is required to descend, w ill be
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code) orthat 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 demolition or dismantling thereof, will be mare than thirty-six (36) feel high: (Chap 3.2, Grp 2 Art 2, Sec 341, Title 8,
subjects the applicant to -a civil penalty of not more than five hundred dollars ($500.): CAC.)
O L,as owner of the property, or my employees with wages as their sole compensation, will clothe work, and the p'As owner -builder, I will not employ anyone'to dotvrork 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 r
through his own employees, provided that such improvements are not intended or offered for sale. If, however, the u, O Division of.lndustrial Safety Perrpit No..
building or improvemnt.is sold within one year of completion. the owner.builder will have the burden of proving thal�, Date, Applicant
he did not build or improve for the purpose of sale.). , CONSTRUCTION'LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
O L 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
Contractor's. License Law.). _ Lender's Address
O'l.am exempt under Sec. . B. 8 P.C. (Attached Certificate). I.certify that I have read this application and state that the above information is correct. ) agree to comply with 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, 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
O'Certified copy is hereby furnished. t- the information given -is correct. I agree to comply with all state laws and county ordinances relating to buidling
O Certified copy is filed'with the City Building Inspection Oepartmeot or City Department. contstruction, and authorize airepresentative of the City of La Ouinta Department of Building and Safety to enter
u the property'for which {I haavefapplied for this permit for the purpose of making inspections.'
Date Applicant
Signature of Applicant or Agent Date
APPLICANT NAME (L, F. tMI)
1> orson Electric
ADDRESS 12735 Deod6k'
CITY/COMMUNITY/STATE/ZIP
Desert Hot Springs, CA
JOB SITE ADDRESS/SPACE -
77-865 Montezuma
CITY/COMMUNITY/STATE/ZIP ' '
La Quinta, CA 92253
BOK
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FIND'
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TRACT
- LOT
-_ TOTAL
FEE •
MOD
SB
TRACT NAME ;
y..,
OWNER NAME (L. F. MI) City of Tr W.
CONTRACTOWFIRM NAME ....
lxcant•
ADDRESS above
CITY/COMMUN ITY/STATEgI�e .
PHONE •
LICNC •
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 0
LICNC
USE OF PERMIT E ect ft ,� 1
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LOT SZ
END
SIDE
Print Applicant/Agent Name
APPUPRMT -HilJDTE 2
L
ot
Permit for 15 -pole lights, 45 inside
lights and flood lights outside.
J�
-_ TOTAL
FEE •
No Fee
s
VALUATION 30,000.00
BLDG. DEPT.
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.
❑
NP'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)
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 Fixtures
31 Service
32 Final
i
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
OFFICE OF THE DIRECTOR
NU\IBER P-1884
CERTIFICATE OF CONSENT TO SELF -INSURE
THIS IS TO CERTIFY, TI COACHELLA VALLEY RECREATION AND PARK DISTRICT
has complied with the requirements of the Director c Industrial Relations under the provisio=ls of
Sections 3700 to 3705, inclusive, of the Labor Code of the State of California and is hereby grantee this
Certificate of Consent to Self -Insure.
This certificate may he revoked at any. time for food cause shown.'
EFFECTIVE: DEPARTMENT OF INDUSTRIAL RELATIONS
OF THE STATE OF CALIFORNIA
1st October 85 G�s
THC --DAY OF—__19-7
A.{,` R. T. RINALDI
•N�c[a
RICHARD S. ANDERSON
a
° Revocation of Certificalc,—••A ccrtific•alc of consent to self -insure may be revoked by the Director of Industrial Relations at any time for ;ood cause after a
hearing. Coad cause includes, among other things, the impairment of the solvency of such employer, the inability of the employer to fulfill his ohlications.. or thr
pmelic•e by such emplrrye.r or his agvnl in charge of the: administration of ohli,rttions under this division of any of the following: (n) Ilabitualiy Cnd as a estte.. of
practicr' and custom indueing claimants for competuation to accept less than the compensation dac or makinm it necessary for them to re'so:•t to pntcv, rriirzs
apinsl the employer to secure the compensation Jur. (h) Dischnraing his cot-, pcnsa l ion oblications in a dishonest mmincr: (c) Dischareim( "is comp rrsati.^rt
ohli.¢alions in such a manner as to cause injury to the public or those, dcaliny with him." (Section .3702 of Labor Code.) The. Ccaificale he re,olvd 's)r
noncompliance. with 'Title 8, California Administrative Code, Croup•^_—Administration of Self -Insurance.
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