0759 (ELEC)PERMIT APPLICATION
City of La Duinta
Department of Building
and Safety "
This permit becomes void.il work not commenced within 180 days from date of,issuance, OR, if work has been suspended or abandoned for a period of,180 days. . .
*that
CERTIFICATE OF EXEMPTION FROM WORKERS" COMPENSATION INSURANCE: This section need not be completed if
' LICENSED CONTRACTORS DECLARATION: I hereby affirm I am licensed under provisions of Chapter 9 -
the permit is for one hundred -($100) o, less. I certify that in the performance of the work for which this permitis', l'
(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 e:
and effect.
California.
License Class' Lic. Number
Date Applicant
Date " Contractor-
NOTICE TO APPLICANT: 11, after,making this;Certificate of Exemption: you should become subject to the Workers'- • '
OWNER -BUILDER DECLARATION: I hereby affirm thaPl aln'exempt from the Contractor's License Law for the
• Compensation provisions of the.Labor Code, you mus forthwith comply with such provisions or this permit shall
- -� - ,
be deemed revoked.
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
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: '
such pqrmit to file a signe0statement that he is licensed pursuantto the prqvisions.of the Contractor's License Law -
0 1 herebylerl[ify that no excavation five (5) ormore feet in depth -into which a person is required to descend. will be
- (Chapter 9(c9mmencing with section 7000) of Division 3 of the Business and Professions Code) or that heis 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, An 2, Sec 341, Title 8,. '
subjects the applicant to a civil penalty of not more than five hundred dollars (5500.): -
C.A.C.)
O I. as owner of the property, or my employees with wages as their sole,compensation, will do the work,and the .
O As owner -builder; I will not employ anyone tli do work which would require a permit from the Division of
structure is not intended or offered for sale (Sec. 7044; Business and ProfessionsCode: 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 himselfor
through his own employees, provided that such improvements are not intended or offered for sale. If, however; the
O Division of Industrial Safety,Permit No.
building orimprovemnt is.sold within one year of completion. the owner -builder will have the burden of proving that.
Date Applicant'-'•
he.didnotbuild:orimprove.torthe purpose.otsale:). Y,..
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the perforrfiance '
%0 I, as owner of the property. am exculsively contracting with licensed contractors to construct the project (Seca :. '
of the work for which this permit is issued (Sec. 3097; Civ. Q. L
X7044. Business and Professions Code: The Contractor's License taw 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 4o the-
-
Contractor's License Law.). -
Lender's Address
O 1 am exempt under Sec.' B. 8: P.C. (Attached -Certificate)':, ---o
I.certify that I'have read this application and state that the above information is correct. I agree to comply with all
Date' Owner ' " �f " <� 'ff . �•' ce — •-�•
city and county ordinances and state laws relating to building construction, and hereby authorize representatives..
. w -•
oI 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
'certificate of Workers' Compensation Insurance , oracertified'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
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
O 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
Signature of Applicant or Agent Date
APPLICANT �NyAME'IL. F MI) )
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ARC/ENG FIRM NAME
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VALUATION�O0
BLDG. DEPT. 'S
'
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
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 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