0644 (ELEC)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days4rom 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: I hereby affirm that I am licensed under provisions of. Chapter 9'
the permit is for one hundred ($110) o, less. I certify that in the performance of the work for which this permit is
"(commencing with'Section 7000) of'Division 3 of the Business and Professions Code, and my license is in lull.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 Contractor
NOTICE TO APPLICANT: If, after. making this Certificateof Exemption, you should become subject to the Workers'
+ •�
OWNER -BUILDER DECLARATION: '1 hereby affirm that I am exempt tram the Contractor'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 asigned statement that heis licensed pursuantto the provisions of the Contractor's License Law -
0 1 hereby certify that no excavation five (5) or more feet in depth into which aperson is required to descend, will be
• (Chapter 9 (commencing with section 7010) 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.ol Section 7031.5 by. any applicant for a permit.
demolition or dismantling thereof, willbe more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2, Sec -341, Title 8, '
subjects the applicant to a civil penally of not more than live hupdred dollars ($50OT
CAC.) '
0 I. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
0 As owner -builder, l will not employ anyoAeF 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
' ',
0 Division Industrial Safely/ Permit No.
through his own employees. provided that such improvements are not intended or offered for sale. If; however; the
of
building orimprovemnt is sold within one year of completion, the owner -builder will have the.burdenofproving that
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
' ❑ 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
Lenders Name
builds or improves thereon, and who contracts -for such projects with a contractorls) licensed pursuant to the
SSB
.Contractor's License Law.). 1_
Lender's Address
❑ I am exempt under Se _-, ` . B. & P..0 ,(Attached Certificate).
I certify that I have read this application and state that the above informationis,correct. I agree to comply with all
DateX X. GA `
Owner " l
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
LOT SZ,
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
END
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
0 Certified copy is hereby furnished. _ .
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 s 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
APP`LICA NA IL. F, MII�,=�f�,
CI %d6mMUNITY/STATFJZIP
JOB'SITE A DDRESS/S�
CITY, /C MUNI,tY/STATE/ZIP r� 1
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PRC
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FINDSSE
TRACT
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Se
TRACT NAME
OWNER NAME (L. F. MI)
CONTRACTOR -FIRM NAME - ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE • j
LICNC •
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
PHONE •
LICNC •
-
USE OF PERMIT -
BL
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FSB
SSB
SSB
RSB
OFC ,
r ZONE ORD N' ..
-
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END
SIDE'
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT n9 4 4 DATE `n
. RE
ED
City of I 184
ka u' t
A
TOTAL
FEE
/ V
VALUATION
BLDG. DEPT.
t
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.
❑
NON
ADDITIONAL INFORMATION
C./�/ � jtyf�
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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
PSL 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