ELEC (0657)52380 Avenida Martinez
0657
PERMIT APPLICATION 3 2;\
r-" City of La Ouinta UU
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 period of •180 days:
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it .
LICENSED CONTRACTORS DECLARATION: 'I .hereby affirm that I am licensed under- provisions of.iChapter .9 .
the:permit.is for one hundred ($100).o, less. I certify that in the performance of the work for which this permit -
• (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
issued, I shall not employ any person in any manner so as,tcrbecoioe slubject to fid'Workers'CompensatioaLaws of
and effect.
Cafiforni , %/ ✓
License Class Lic. Number
Date ;31;z Applicant
Date - Contractor '"
N ICE TO APPLICANT: If, after making this Certificate of Exemption: you should become subject to the Workers'
OWNER•BUILOER DECLARATION: 1 hereby atfirm that I' am exempt from the Contiactor'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
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 -
❑ 1 hereby certify that no excavation five (5) or more feet in depth intowhich a perion is required to descend, will be
(Chapter 9_(commencing with section 7000) of.Division.3 of the Business and Professions Code)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 o1.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, Title8,
subjects the applicant toa civil penalty of not more than five hundred dollars (SSOOq::..
C.A.C.) "
' 0 1. as owner of the property, or my employees with. wages as their sole compensation, will do the work, and the
• p 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 Contractors 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
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through his own employees, provided that such improvements are not intended or offered for sale. If, however, the
,' 0 Division of Industrial Safety Permit No.
building or improvemni is sold within one year of completion, the owner -builder will have theburdenofproving that ••
'Date Applicant
. he did, not build or improve for.the,purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a constructiori lending agency for the performance '•.
O 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
..
Contractor's License Law.).
Lender's Address
O I am•exempt'under Sec. B..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
.gate - Owner
city and county ordinances and state laws relating to building construction; and hereby authorize representatives
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of -this county to enter upon the above-mentioned property for inspection pftoses.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
END•. -
certificate.ot 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'applicationand state that
0 Certified copy is. hereby furnished. a •
-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 Department or City Department
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
'
upon the property for which I have applied for this permit for the purpose of making inspections. .
Date Applicant
APPLIC-ANT NA It
e
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CITY/ O MyMUNITY/STATE/ZIP ,q
JOB,%TE ADDRESS/SPACE -
CIT}/COMM I NI Y/STATE/ZIP '
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PAG
PRC
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TWN
RNG
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TRACT
LOT
TOTAL •
FEE -
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SB
TRACT NAME
OWNER NAME (L. F. MI) .. '
CONTRAC OR -FIR NAME
Tom-• / .
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ADDRESS
71'/`cJC / /✓T 11_7
CITY/COMMUNITY/STATE/ZIP f
PHONE •
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-
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONE •
LICNC •
USE OF PERMIT -
BL
ZON
FSB
SSB
SSB-
RSB
OFC_
ZONE ORD • ..7
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END•. -
SIDE
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT 0A ! '/ ..
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l City of La uirdla
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TOTAL •
FEE -
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BLDG. DEPT. VALUATION /
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
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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