Loading...
0056 (ELEC)PERMIT APPLICATION City of La Ouinta �j 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. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Date Contractor Lic. Number OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the 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 such permit to tile a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): 0 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the 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, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvemnt is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for the purpose of sale.). 0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.). 0 1 am exempt under Sec. Date Owner B. 8 P.C. (Attached Certificate) 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.). Policy No. Company 0 Certified copy is hereby furnished. 0 Certified copy is filed with the City Building Inspection Department or City Department. Date Applicant AM F. MI) PePLJFt r13-ik.. ,M HAY In CITY/,COM MUN ITY/STATE/ZI P Daum L*se t, CA 92260 JOB SITE ADDRESS/SPACE ACA— 78-347 Highway In CITY/COMMUNITY/STATE/ZIP BOK PAG PRC C TWN RNG SE S TRACT I I LOT Cb- of La QWnU TOTAL FEE MOD SB TRACT NAME OWNER NAME (L. F. MI) CONTRACTOR -FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE N LICNC N ARC/ENG FIRM NAME ADDRESS CITY/COMMUNITY/STATE/ZIP PHONE N LICNC N USE OF PERMIT BL ZON FSB SSB SSB RSB OFC ZONE ORD N LOT SZ I ND SIDE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the permit is for one hundred ($100) It. less. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation laws of Califeornia. (/ DatJ y n jf Applicant / 1 �� NOTICE TO APPLICANT: If, after making this Certificate of Exemptionbld, you shobecome subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: 0 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341. Title 8, C.A.C.) 0 As owner -builder, I will not employ anyone to do work which would require a permi! from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from that division, 0 Division of Industrial Safety Permit No. Applicant 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.). Lender's Name Lender's Addre I certify that I have read this application and state that the above information is correct. I agree to comply with all 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. Signature of Applicant or Agent Date 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 construction, and autporize a representative of the City of La Ouinta Department of Building and Safety to enter upoygrthe property I)vwhich I'have applied for this permit for the purpose of making,mspec`tions. l Al A Signature o1 Applicantnr Agent! Date Print Applicant/Agent Name APPUPRMT `� C(1 l y� 56 aA,T�`h� �( j, jf Pet in W add Mi �.m to ,, y,��.,� ��,,a�,,��, yy ����,�,�.�'^M xi ;LUV F1�ctx�,c pmxnit fee $ 10.00 t�isaei7.�t1 Waring 12.00 ::205!/AX 11 1u) §wum INV LMU FES 141993 Cb- of La QWnU TOTAL FEE UU VALUATION $1,400.00 Arrow Printing 250/1-83 White: Finance Canary: Assessor Pink: Applicant Tag: Bldg. Dept.