ELEC (0594)PERMIT APPLICATION
City of La Ouinta
-Department of Building and Safety
This permit becomes void it work not commenced within 180 days from date of issuance. OR, it work has been suspended or abandoned for a period of 180 days
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if .
LICENSEDCONTRACTORS DECLARATION: I hereby affirm that I am.licensed under provisions ol'Chapter .9.
: the -per mit 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 o1 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 tothe .Workers' Compensation Laws of
and effect.
California.
License Class Lic. Number
Date Applicant
' Date " ' "' Contractor ^' - ' '- ',
;.. -.NOTICE TO APPLICANT: If; altermaking this Certificate of Exemption, you should become subject to the Workers' • .
' OWNER-BUILDER'OECLARATION: I hereby affirm that I am exempt from the Cont'ractor's�License Lawlor 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 permitto fileasigned statement thathe.is licensed pursuant to the provisions of the Contractor's License Law.,
0. 1 heieby'certify that no excavation five (5) or more feet in depth into which 4 person is required to descend, will be'
(Chapter 9 (commencing.with section 7000) of Division 3.of the Business and Professions Code) or That he isexempt ,
made inconnectiomwilh work authorized bythis permit, and that no building structure, scaffolding,.falsework; or
therefrom and the, basis for the alleged exemption: Any violation of Sectio6,.7031:5 by any applicant fora permit
demolition ordismantling thereof, will be more than thirty-six (36) -feet high. (Chap 3.2, Grp 2 Art2, Sec -341, Title 8.
. subjects the applicant to a civil penalty of not more. than five hundred:d01lars.($500.):. -
C.A'.C.) -
.0.1. as owner of the property, orally employees with wages as their sole compensation, will do the work, and the . _
'0 As -owner -builder, I wilbnot 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 ..
u.
0 Division,of Industrial Salety.Permit No.
'through his own employees, provided that such improvements are not intended.oroffered for sale. -If. however, the
PHONE*
building orimprovemntissold within one year ofcompletion, the owner -builder will have theburdenofproving that.
Date r Applicant
It did of build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY:. i hereby affirm that there is a construction lending agencytor ttie performance
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
Lende'r's Name '
builds or improves' thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the
SSB
Contractor's License Law.). . . IY r� c
Lender's Address
I1 under!Sec % i .. B &P.C..(Attached Certificate)
I certify:that 1 have read this application,and state that the above information is correct. I agree to comply with all
,a/rtl�xempt
' Dates" �t{''f r {' ' Owner rY✓t• -�—✓�
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
r t --r v tis •
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
m,certificate of Workers' Compensation Insurance, or a certified copy thereof (See.'3800. Lab. C.),
Signature of Applicant or Agent ' Date
Policy No. Company .
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`CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: fce}tify l have read this application and state that
o Certified copy.is hereby furnished. ..
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 . •,
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upon the property loi,which I have applied for this permit for the purpose -of making inspections. .
Date Applicant
W
Signature of Applicant or Agent Date
rt
Print Applicant/Agent Name
APPLICANT
ADDRESS %� � .•,.. ., ,
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CITY/COMMUNITY/STATE/ZIP
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CITY/COMMUNITY/STATE/ZIP
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TRACT NAME -
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME - •.
ADDRESS
CITY/COMMUNITY/STATE/ZIP -- -
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LICNC 0
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ARC/ENG FIRM NAME -
ADDRESS '
CITY/COMMUNITY/STATE/ZIP -
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LICNC 8
USE OF PERMIT
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: END
- SIDE.
'V'ALUATION;• ,
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVAL'S
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.
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NON ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12
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