0681 (MECH)PERMIT APPLICATION
City of La ouinta
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.:
'
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 ($100) o, less. I certify that in the performance of the work for.which this permit is
"(commencing with Section 7000) of.Division Sof the Business and Professions Code; and my license is in full force
issued;.) shall not employanyperson 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: It, after making this Certificate of Exemption, you should become�subject to the Workers'_-.,
'hat I am exempt fromthe Contractor's License Law -for the
OWNER -BUILDER DECLARATION: I hereby'-affirmet
Compensation provisions of the Labor,Code, you must forthwith comply with such provisions or this-permitshallv .
deemed revoked. a
.following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
.be ,
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: r
such permit to file a signed statement that he is licensed pursuant to the provisions ofthe Contractor's License Law.C1
I heieby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be!
(Chapter9 (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, fafsework, or
•. therefrom and the basis for.the,alleged exemption. Any violation of Section 7031.5 by any applicant for a permitdemolition
or dismantlingthereot, will be more than thirty-six (36) feet high. (Chap 3.2, Grp•2, Art 2, Sec 341, Title 8,"
subjects the applicant to a,civil penaltyof not more than five hundred dollars ($500.):
CAC )' s `:1.
-' 0 I, as owner of the property, or.my employees -with wages as,their,sole compensation, will do the work, and the
❑ 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 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'
w
'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 or improvemni is.sold within oneyear of completion. theowner-builder will havethe burden of pjpving that.
Date Applicant
he did not build or improve for the purpose of safe,).
CONSTRUCTION LENDING AGENCY: Ihereby affirm that there is a construction lending agency for the performance'
0 L 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
• builos or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the'
_
Contractor's License Law.).
Lender's Address
0 1 am exempt under'Sec.- B. 8 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
Date Owner
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.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that have a certificate of consent:to self -insure; or a'
-
certificate of Workers''Compensation Insurance . or a certified copy thereof (Sec. 3800.•Lab: C:).
Signature of Applicant of Agent Gate
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
0 Certified copy is filed with the City Building Inspection Department or City Department.' •
construction, and authorize a'representative of the City of La Guinta 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
APPLICANTNAL}(/L.. F; MI) /
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ADDR/ESS,
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CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE -
CITY/COMMUNITY/STATE/ZIP
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PAG I
PRC
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TRACT
LOT
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TRACT NAME -
OWNER NAME (L. F. MI)'
CONTRACT R•FIR.M
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ADOq SS
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE n
LICNC tr
TOT,AL`.'�
USE OF PERMIT
BL
-
ZON
FSB
SSB
- SSB
RSB
OFC
- ZONE ORD • • ' •�
•' LOT SZ
END
SIDE,
Print Applicant/Agent Name
APPL/PRMT
DArE
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!V
N.
TOT,AL`.'�
VALUATION.
- BLDG. DEPT.
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
2 (� /
/U/3�
—
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R"i
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/I
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32" Final