0398 (ELEC)PERMIT APPLICATION
x 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 completed it
LICENSED. CONTRACTORS DECLARATION: I hereby affirm- that 1, 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 3•ol.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 to the Workers'Compensation Laws of
and effect
California.
:.License.Class* Lic. Number
Date Applicant
Date`Contractor
�... _i ,NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' . •'
OWNER-BUILDER�DECLARATION: 'I hereby affirm that I am exempt from the Contractor's License Law for the .`•
L� .. 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:
alter,
construct, 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 a signed statement that he is licensed pursuant to the.provis ions of the Contractor's License Law
0 [hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend.w ill be
.(Chapter 9(commencing with secfion.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,tafsewo'k, or
therefrom and the basis for thealleged exemption. Any violation of Section.7031.5 by any applicant -for. permit), '. •
demolition'or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec341, Title 8;
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.): Jaa :v::. '
- C.A.C:)-
0'1, as owner of the: property, or my employees with wages as their sole compensation, will do the work, and. the
- .0 'As owner-bililder,•1 will not'employ anyone to. do work which would require a permit frdm the Divisi en.of
• . structure is not intended or offered for safe (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, avid who does such work himself or
_
- dhrough his own employees. provided that suchimprovements are not intended or offered for sale. If, however, the
❑ Division of Industrial,Safety Permit No.
building orimprovemntissoldwithin one year ofcompletion:the,owner-builder will have the burden ofprovingthat
Date - Applicant
he did not build or improve for -the purpose of sale.).- .
CONSTRUCTION LENDING AGENCY: I hereby affirm thatiliere is a construction lending agency for the.perfornance
O 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 '
Lender's Name
builds. or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the :'
.
Coniractor:s License Law.).
Lender's Address
-o. I am exempt.under Sec' • . B. & P.C. (Attached Certificate):
Lcertify thatl have read this application and state that the above information is correct: l agree to comply wi h all
fZ r ' ,1. :, yc �' , , % ��t w `.,`,_,
' Date •= Owner y
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. F
WORKERS' COMPENSATION DECLARATION: I hereby affirm that•l,have a certificate of consent to self -insure, ora
.certificate of Workers' CompensatiogJnsurance' or a certified copy.thereof (Sec.•3800. Lab. C.).
END .
. - .
Signature of Applicant or AgentDate
Policy No.` Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY:- I certifyI have'read this application and state that
.O Certified copyis hereby furnished.
the information given is correct. I agree to comply -with all state laws and county ordinances relating to buiJling - `r
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 NAME (L. F. MI) �,.O -
ADDRESS j7 49&Dy J / 3S
CITY/COMMUNITY/STATE/ZIP. ..
P44 M
JOB SITE ADDRESS/SPACE
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CITY/COMMUNITY/STATE/ZIP
• 41
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BOK
PAG
PRC
C
TWIN
RING
SE
S
TRACT
MOD
- SB
TRACT NAME
OWNER NAME (L. F. MI) ^
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CONTRACTOR -FIRM NAME • ..
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE. A
LICNC 4
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC
USE OF PERMIT ..
BL
ZON
FSB
SSB
SSB ,
RSB
OFC '
ZONE,ORD' 0, • _ -
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..
END .
SIDE
Print Applicant/Agent Name
APPVPRMT DATE�
.pOG F
R E C E if
1983
City 'If a
' Y
i'"'TOTAL
EE
Zug _
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. ❑
NOADDITIONAL INFORMATION
1.2/16�g�'�-
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
STREET NAME
P/t
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32_ Final