ELEC (0115)52470 Avenida Madero
0115
- PERMIT APPLICATION
-
CITY/COMMUNITY/ST,ATE21_P.
LWjp
City of
Department of Building
La Ouihta
and Safety,-
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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.• ' -
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LICENSED CONTRACTORS DECLARATION: •I hereby affirm that I am licensed under provisions of Chapter 9 "
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it
:Ahe 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 3of the Business and Professions Code, and my license 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 ContractorNOTICE
TO APPLICANT: It, after making this Certificate of Exemption, ,you should become subject to the Workers'
OWNER -BUILDER DECLARATION: 1 hereby affirm that I am exempt from the Contractor's License Law for theCompensation
_
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 c
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 CERTIFICATION:
such permittoJile a signed statement thathe is licensed pursuant to lhe provisions of the Contractor's License Law
Olherebyceriifythatnoezcavatiopfive(5)ormorefeetindepthintowhichapersonisrequiredtodescend,willbe
(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 more than thirty-six (36) feet high. (Chap 3.2, Grp 2; Art 2, Sec341, Title B,
subjects the applicant to a civil penally of not more than five hundred dollars ($500.):
C.A.C.)
l. as owner of the properly, 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
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself or
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
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through his own employees, provided that such improvements are not intended or offered for sale. It, however, the
0 Division of Industrial Safety Permit No.
building orimprovemntissold within'oneyear ofcompletion. the owner -builder will havethe burden of proving that
Date Applicant
he did not build improve for the purpose of sale.).
-
t.
0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec.
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.).
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
0 1 am exempt under Sec. B. 8 P.C. (Attached Certificate).
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I certify that I have read this application and state that the above information is correct. I agree to comply with all
Date Owner li
city and county ordinances and state laws relating to building construction, and hereby authorize representatives •
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
of this county to enter upon the above-mentioned property for inspection purposes.
certificate of Workers' Compensation Insurance , or a certified copy thereof'(Sec. 3800. Lab. C.).
Policy No. Company
Signature of Applicant or Agent Date
❑ Certified copy is hereby furnished.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
0 Certified copy is filed with the City Building Inspection Department or City Department.
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
Date Applicant
upon th` perty for which I have applied for this permit for the purpose of making inspections.
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Signature of Applicant or Agent , Date -
APPLICANT NAME,(L„FF, M,II)).q
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ADDRESS
CITY/COMMUNITY/ST,ATE21_P.
LWjp
JOB SITE ADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
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END
SIDE,
Arrow Printing 250/1-83'
White: Finance,
Print Applicant/Agent Name
APPUPRMT 1x 1g Mpg f +iDATES - -
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TOTAL
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Canary: Assessor' Pink. Applicant TayN: 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
f=ireplace T.O.
❑
NON
ADDITIONAL INFORMATION
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick al
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/1
'STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final