0331 (ELEC)PERMIT APPLICATION �\
City of La Ouinta
Department of Building and Safety
This permit becomes void i1 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
Contractor
Lic. Number
OWNER -BUILDER DECLARATION. I.haraby affirm that I am exampl tram the Contractor's License Law for the
fallowing reason (Sec. 7031.5, Business and Prolesslons Code: Any city Or county which requires a per mil to
coastrutt, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
such permi110 (1[a a signed statement that he is licensed pursuant to the provisions of the Coal ractor'sLicense Law
(Chapter 9{commencing with section 7MOI of Dlvtsion 3 of the Business and Prof minas Code) or that he is exempt
therefrom and the basis for the alleged exemption. Any violation of Section 11k31.5 by any appllcanf for a Ormdt
subjects the applicant to a civil penafty dl not more than live hundred dollars (M.);
❑ I, as owner Othe properly, or my employees with wages as their sole compensation, will do the work, and the
structure Is not Intended or offered for sale iSec. 7044. Business and Prolessions Code: The Coniractor'sLicense
Law does not apply to an owner OI property who builds, or improves Ihereon.and who does such work himself or
through his own employees, provided that such Improvements are not Intended or offered for sate, 11, however, the
building or i mprovemnt is sold within ane year o1 cOmpfetron, Ih a owner-buifdar will have the burden of proving that
he did not build or Improve for the purpose of sale,).
❑ 1, as owner of the properly, am exculslvetycontracting with IIcansed contractors to canstruel the project (Sec.
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
builds a Improves thereon. and who toatracts for such projects with a conitactorlsj licensed pursuant To the
Contractor's License Law.).
b I am exempt under Sac. E. & P.C. (Attached Certificate).
Data Owner —�
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
Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the City Building Inspection Department or City
Date Applicant ..
Department
APPLICANT NAME (L, F, MI)
ADDRESS
CI TY/C D MMUNI TY/STATEMP
- ,
JOB SITE ADORESVSPACE
CIT YICOMMUNI T YISTATE iDP
BOK PAG PRC C
TWN
PING SE
S
TRACT
LOT
MOD
SB
TRACT NAME
OWNER NAME (L. F, MI)
CONTRACTOR -FIRM NAME t,
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC x
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC
USE OF PERMIT
BL
20N
FSB
SSB
SSB
RSB
OFC
ZONE ORD M
LOT SZ
END
SIDE
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred (S100) o, less. I certify that in the performance of the work for which [his permit is
issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of
California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation prov isions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby cattily tbat no excavation five (5) or moreieat in depth into which a -Orson in required to descand. w ill be
made in connection with work authorized by this pormit,and thatno building structure, seafldlding, falsework, or
demohlicm ordismantling thereof, will be more than thirty-six (36) lei] high, (Chap 32, Grp 2, Art 2, Sec341. Title 8,
C.A.C.)
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No
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 Address
I certify that I have read this application and state that theabove information is correct I agree to comply with all
city and county ordinances and state tawsmialing 10 building construction, and herebyauthorize representatives
of this county to enter upon the above-menlionad property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certily I have read this application and state that
the information given is correct I agree to comply with all state laws and county ordinances refaling to buidling
construcllon, and authorize a represantafive of the Cily of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied far this OrmR for the purpose of making Inspections.
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT DATEcg
'
of
TOTAL .
FEE • Zr ✓ C,
BLDG. DEPI7. VALUATION , f C/ - --� c11
NO.
1
2
2A
3
4
5
6
7
8
9
10
10A
11
12
12A
13
OPERATION DATE
BUILDING APPROVALS
Set Back
Ftgs & Frms
Slab Grade
Steel
Grout Blocks
Bond Beams
Roof Deck
Framing
Vents
Garage Fire Wall
Fireplace P.L.
fireplace T.O
Exterior Lath
Internal Lath
Drywall
Finish Grade
INSULATION
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
u
Thick Vaall
ue
PLUMBING APPROVALS
INSPECTOR NO,
OPERATION
I DATE
MECHANICAL
APPROVALS
33
Ventilation System
34
Plenums & Ducts
35
Furnace Compart.
36
Inlets & Outlets
37
Combustion Air
38
Compressor
39
Appl. Clearance
40
Fire Damper
41
Smoke Detection Device
42
Commercial Hood
43
Final
OP'N
ADDITIONAL INFORMATION
]NO.
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
ELECTRIC APPROVALS I
26
Power Pole
D d
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
29B
Bonding
30
Fixtures
31
Service
32
Final
INSPECTOR
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
REAR OF PROPERTY LINE
STREET NAME