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0201-076 (MISC)79754 Arnold Palmer LICENSED CONTRACTOR DECLARATION — — — •---————_. .——— I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT PERMIT// F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE i VALUATION LOT t: 7ll)1-t17 , TRACT c4 W Professionals Code,and my License is in full force and effect. 5 License# Lic.Class Exp.Date I v ADDRESS 7F 75-21 f JOB SITE APN Z r-- Date /' ' ' '''--Signature of Contractor OWNER CONTRACTOR/DESIGNER/EN (NEER Or r- _ C OWNER-BUILDER DECLARATION U W PGA,VTRS'a' Wa I hereby affirm under penalty of perjury that I am exempt from the Contractor's P(l) (0 License Law for the following reason: property, or my employees with wages as their sole s.i:/;?t.?S.Tt'I'R CA 911251.3 f i\Fti fliT lsY".Co .}1;,40 +• ?ilU7 _ ( ) I, as owner of the compensation,will do the work,and the structure is not intended or offered for (A-S";(it) f[' 1.,1`i 5823 sale(Sec.7044,Business&Professionals Code). USE OF PERMIT as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Nii01 `.I:L;T 14..1'"_(.yIY0 Code). O I am exempt under Section , B&P.C.for this reason f:=tt1L,t;1tJS:f Jy• i;'>76r, "79 l; t;,';o.iA6,;Y..Y3g. tJtjL.►.1Tt'i'l,.i:Y O N Date Signature of Owner 5`I"7?i.iOT1.111A II:i40011WIC•! 'I'ONS 0)a Q WORKER'S COMPENSATION DECLARATION o I hereby affirm under penalty of perjury one of the following declarations : H p ( ) I have and will maintain a certificate of consent to self-insure for workers' :;Al t) Iit;,1.1 :t)l1Gfl.Utl i X W compensation, as provided for by Section 3700 of the Labor Code, for the mJ Q performance of the work for which this permit is issued. Q V (!) I have and will maintain workers'compensation insurance,as required by O Q Section 3700 of the Labor Code, for the performance of the work for which this a 0) H permit is issued. My workers' compensation insurance carrier & policy no. are: V Z Carrier Policy No. ob v .87,AA1;:T00'HO H601111HIT090941 .f l.lt tli' J)CQ?a P C)F C:f)N1N'11t :1C'11()IY Rf),(FtN?.Q>E1 g (This section need not be completed if the permit valuation is for$100.00 or less). tai'"r7.IVli.l FEE!vU•NY•iVdAkkY ( ) I certify that in the performance of the work for which this permit is issued, C N'r31ALI'.'-" 10]" FEi i I[))-110()-J)s3.QOp 1fil,O(s 1 shall not employ any person in any manner so as to become subject to the ;;`I RONO ?/.iC?TY74N FIV ;• 1;.E ID 10 1-000-24 1-000 workers'compensation laws of California, and agree that if I should become 3 subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those,provisions. / Date: ` Applicant Warning: Failure to secure Workers'Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to$100,000,in addition to.the cost of compensation,damages as provided for in Section 3706 of the Labor Code,interest and attorney's fees. ' IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his , application. 4 i 1.Each person upon whose behalf this application is made&each person at whose request and for whose benefit work is performed under or pursuant to ;}tiCi-TCf!`Ai:.t,Yl• ldati'f 1}CJCo'.f'iC>1!'r;N.l)]'' :h,hl f',1 ihc.`f; ! q.tlii tlti \ any permit Issued as a result of this applicaton agrees to,&shall, indemnity Z A:9j] 00%1;41A1 ' r',.",F;) map & hold harmless the City of La Quints, its officers, agents and employees. 2.Any permit Issued as a result of this application becomes null and void if work Is not commenced within 180 days from date of issuance of such 7`Ob%Aa<..: ':fd. ? f3'3'I "M,.k.S DUF PTC W 'C.?th'd,Rztl permit,or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is I IIII II VIII 1111 1111 IIII 20 • correct. I agree to comply with all City, and State laws relating to the building IE construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. ; RECEIPT DATF BY-. DATE FIPALED INSP CT Signature (Owner/Agent) I '1Z ! ' / .t ! (.' Date '' •/ ' t ,./ / ,t. .`' a Z ------------ INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms&Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K.to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans&Controls Party Walt Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall-Int.Lath Final Final POOLS - SPAS BLOCKWALL APPROVALA steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equiomer!Location Underground Electric Underground Plbg.Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Neater Final Wat,ar Piping Flumbing Final Plumbirg Top Out Equipment.Enclosure Shower Pans O.K.for Finish Platter Sewer Lateral Pcol Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMSVTTS' Final ' Utility Notice(Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit I Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels / ' Exterior Receptacles G.F.I. Smoke Detectors j Temp.Use of Power Final A Rility Notice(Perm) IIIIIIIIVIIIIIIVIIIIIII 21 IE P.O. BOX 1504 No. 002743 Building 78-105 CALLE ESTADO Address 79--754 Arnold Falb LA QUINTA,CALIFORNIA 92253 Owner amcim QMVWW Mailing BUILDING: TYPE CONST. OCC.GRP. Address 75-005 OmltrX CIb Drive A.P. Number CityZip Tel. Palm � . 92260 568o-2829 Legal Description Contractor Project Description TI WRRr PM-CIT, 13 13 Vnti, gl Mei# TATV Address y PIM 10 0 City — Zip Tel. State Lic. City �2 &Classif.�RRZ Lic.# 32R Sq. Ft. No. No. Dw. Arch., Engr., Size 552 • Stories Units - Designer New B Add ❑ Alter ❑ Repair❑ Demolition ❑ Address Tel. City Zip State Lic.# - _ LICENSED CONTRACTOR'S 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 its in-ffbllll force and effect. � � .. r' /.—,i.,.il.-f /./.f,/' .�.1-+•rte _ SIGNATURE DATE r'OWNER-BUILDER DECLARATION ' I hereby affirm that I am.exempt from the Contractor's License Law for the following Estimated Valuation 144,53.7.00 � z�Z•�V^ reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a f J permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also AMOUNT requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that.he is exempt therefrom, and the basis Plan Chk. De for the alleged exemption. Any violation of Section 7031.5 by'any applicant for a permit p - subjects the applicant to a civil penalty of not more than five hundred dollars($500). . tis ea ❑I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. 462.89 do the work,and the structure is not intended or offered for sale.(Sec. 7044,Bussness and Const. ��" Professions Code: The Contractor's License Law does not apply to an owner of property who • builds or improves thereon and who does such work himself or through his own employees, Mech. SS �d provided that such improvements are not intended or offered for sale. If, however, the building - • or Improvement is sold within one year of completion, the owner-builder will have the burden Electrical' ��� ' of proving that he did not build or improve for the.purpose of sale.) • ❑ I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing struct the project. (Sec. 7044, Business and.Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for S.M.I. 0,itA such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) Grading ❑.I am exempt under Sec. B.8 P.C.for this reason Driveway Enc. Date owner Infrastructure O �� WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure, or a certificate of Worker's Compensation Insurance,or a certified copy thereof.(Sec.3800,Labor Code.) Policy No. Company O Copy is filed with the city. ❑Certified copy is hereby furnished. TOTAL CERTIFICATE OF EXEMPTION FROM REMARKS WORKERS'COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of thg work for which this 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 Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption youshould become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Minimum Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setback from Center Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code.) Side Setback from Property Line Lender's Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out,signed and validated,and is subject to expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. Issued by: Date x - ^ r'tPermit I agree to comply'with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter th:Z;14" above- mentioned property for inspection purposes. �,� Validated by: Signature of applicant '� ! Date ! ', Mailing Address f '" '� J� f Validation: City, State, Zip A6 % 52 11 14 33 , 39L Ch HARD COPY CONSTRUCTION ESTIMATE NO. ELECTRICAL k ES NO. PLUMBING FEES IST FL. SQ.FT.® $ UNITS 2ND FL. SQ.FT. YARD SPKLR SYSTEM POR. SO.FT.® MOBILEHOME SVC. BAR SINK GAR. SO.FT,® POWER OUTLET ROOF DRAINS CAR P. Q.FT. DRAINAGE PIPING WALL SQ.FT. DRINKING FOUNTAIN SO.FT.® URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE:Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE,TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SQ.FT.®c BATH TUB SQ.FT.®c WATER HEATER MAX.HEATER OUTPUT,B.T.U. SQ.FT.RESID®11/e c SEWAGE DISPOSAL SQ.FT.GAR® 3/ac HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST.FEE ELECT.FEE SMI FEE PLUMB.FEE STRUCTURE PLUMBING ELECTRICAL HEATING&AIR COND. SOLAR SETBACK ROUND PLUMBUNDERGROUND A.C.UNIT COLL.AREA LAB GRADE OC ROUGH PLUMBS 7 c-on BONDING HEATING(ROUGH) STORAGE TANK FORMS LSEWER OR SEPTIC/A / ROUGH WIRING 3�') l DUCT WORK ROCK STORAGE OFOUND.REINF. , .a I `O GAS(ROUGH) t METER LOOP r HEATING(FINAL) OTHER APP.IEQUIP. ��--✓✓ REINF.STEEL /fFINAL) G/r C__� TEMP.POLE GROUT WATER HEATER / SERVICE NAL INSP.��S� BOND BEAM WATER SYSTEM GRADING LUMBER GR. INAL INSP) V'N cu.y d. ^� fy FRAMING n INALINSP. $ plus x$ $ OOFING REMARKS: 1261 . ! C ) I.2/ 7 VENTILATION rC FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL ifL!�LATHING (teMESH ee p INSULATION/SOUND �� 0 FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES11NITIALS. GARDEN WALL FINAL IIIIIIIIIIIIIIIIIIIIIIIII 22 w IE 4 P.O.BOX 1504 No. 14889 Building 78-495 CALLE TAMPICO Address 79-7.54 Arnold Palmer LA QUINTA,CALIFORNIA 92253 Owner Mailing Jeff Silveira BUILDING: TYPE CONST. OCC.GRP.- Address 79»754 Arnold Palmer A.P. Number City Zip Tel. La Quinta 92253 771-1734- Legal Description Contractor. Preferred Plumbing Project Description Address. 4511 Sunny Dunes City Zip Tel.: Palm Sp rings 92254 .322-3173 State Lic. City &Classif. C36,C-16 457354 Lic.# 2229 Sq.Ft. No. No.Dw. Arch., Engr., Size -Stories Units Designer New ❑ Add ❑ Alter ❑ Repair❑ Demolition ❑ Address Tel. Add 71 Gas. Line City Zip State Lic.# LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)t of Division 3 of the Business- and Professions Code,and my license is in full force and effec SIGNATURE DATE OWNER-BUILDER DECLARATION Estimated Valuation I hereby affirm that I am exempt from the Contractor's License Law for the 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 i requires the applicant for such permit to file a signed statement that he is licensed pursuant to PERMIT AMOUNT the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, or that.he is exempt therefrom, and the basts, for the alleged exemption. Any violation of Section 7031.5 by'any applicant for a permit.- Plan Chk. Dep. subjects the applicant to a civil penalty of not more than five hundred dollars($500). ❑I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and Const. 30• Professions Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon and who does such work himself or through his own employees, Mech. provided that such Improvements are not Intended or offered for sale..lf, however, the building orImprovement is sold within one year of completion, the owner-builder will have the burden Electrical of proving that he did not buikl.or Improve for the purpose of sale.) ❑I,as-owner of the property,am exclusively contracting with licensed contractors to con- Plumbing struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does-not apply to an owner of property who builds or Improves thereon, and who contracts for S.M.I. such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) • ❑1 am exempt under Sec. B.8 P.C.for this reason Grading Driveway Enc. Date Owner Infrastructure WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Worker's Compensation Insurance,or a certified copy thereof.(Sec.3800,Labor Code.) Policy No. Company ❑Copy is filed with the city. ❑Certified copy is hereby furnished. TOTAL #.>V•VU CERTIFICATE OF EXEMPTION FROM REMARKS WORKERS'COMPENSATIONINSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of thg work for which this permit is issued,I shall not employ any pperson in any manner so as to become subject to the Workers'Compensation Laws of California. Dale Owner NOTICE TO APPLICANT: n, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Minimum Setback Distances: ' Front Setback from Center Line Rear Setback from Rear Prop.Line WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND Side Street Setback from Center Line_ SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES'UP TO ONE .HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION.TO THE COST OF COMPENSATION, Side Setback from Property Line DAMAGES AS PROVIDED FOR IN SECTION 3706.OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. FINAL DATE INSPECTOR This is a building permit when properly filled out,signed and validated,and is subject to expiration if work thereunder is suspended for 160 days. I certify that I have read this application and state that the above information is correct. Issued by: ' Date Permi I agree to comply with all city and county ordinances and state laws relating to building /ZYV construction, and hereby authorize representatives -of this city to enter the above-. i mentioned property for inspection purposes. Validated by: 1n Signature of applicant— Date Mailing Address Validation: MAR 1 4 3995 City, State, ZIp CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBINU FEES 1ST FL. SO.FT.® $ UNITS ) 2ND FL. SO.FT. YARD SPKLR SYSTEM POR. SO.FT.® MOBILEHOME SVC. BAR SINK GAR. SO.FT.® POWER OUTLET ROOF DRAINS CAR P. SO.FT.® DRAINAGE PIPING WALL SO.FT. DRINKING FOUNTAIN SO FT ® URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE:Not to be used as properly tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASH ER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE,TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO.FT.®c BATH TUB SO.FT.®c WATER HEATER MAX.HEATER OUTPUT,B.T.U. SO.Fr.RESID®1 Vi c SEWAGE DISPOSAL SO.FT.GAR®V4c HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST.FEE ELECT.FEE SMI FEE PLUMB.FEE STRUCTURE PLUMBING ELECTRICAL HEATING&AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C.UNIT COLL.AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING(ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND.REINF. AS(ROUGH) �—/ L C METER LOOP HEATING(FINAL) OTHER APPJEOUIP. F17 —REINF.STEEL �,AS(FINAL) l TEMP.POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING , LUMBER GR. FINAL INSP. cu.yd. FRAMING FINAL INSP. $—Plus—X$—=$ ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES/INITIALS GARDEN WALL FINAL P.O.Box 1504 APPLICATION ONLY Building �f // 7f-105 CALLE ESTADO Address ` 75 ✓io64 d/✓lt�LA QUINTA,CALIFORNIA 92253 Owner /` �!_ r � BUILDING: TYPE CONST. OCC.GRP. Mailing /'/ Address 2 - JSI� ✓h c7`� GJ 1il"_ey/' A.P.Number Legal Description Contra Project Description f Address Cjt Zip Tel. a State Lic. Citlioy &Classif. G Lic.# Sq.Ft. No. No.Dw: Size Stories Units Arch.,Engr., Designer New ❑ Add ❑ Alter❑ Repair ❑ Demolition ❑ Address Tel. V 0 , City Zip State Lic.q L'CEq0o CONTRACTOR'S DECLARATION I hereb a irm th m I!c sed under provisio �VhaTpter 9(commencing with Section 7000)of v' i o e B iness and fessi d my licenseis'n full d effect 10 GfJ URE OWNER-BUILDER LARATION' Estimated Valuation I hereby affirm that 1 am exempt from-the Contractor's License Law for the following reason: (Sec. 7031.5,Susiness and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such permit to rile a signed statement that he is licensed pursuant to PERMIT AMOUNT the provisions of the Conhactor•s License Law, Chapter 9 (commencing with Section 7000) or Division 3 of the Business and Professions Code. or that.he is exempt therefrom, and the basis plan Chk. De for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit Plan subjects the applicant to a civil penalty of not more than five hundred dollars($500). !-!I,as owner of the property,or my employees with wages as their sole compensation,will Plan Chk. Bal. do the work,and the structure is not intended or offered for sale.(Sec. 7044,Buisness and Const. Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through his own employees. Mech. provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden Electrical of proving that he did not build or improve for the purpose of sale.) 1 1 I,as owner of the property,am exclusively contracting with licensed contractors to con- Plumbing 0 C-) struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for S.M.I. r such projects with a contractor(s)licensed pursuant to the Contractor's License Law.) Grading C:I am exempt under Sec. B.8 P.C.for this reason Driveway Enc. Date Owner Infrastructure WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self-insure,or a certificate of Worker's Co ensation Ins nce,or a certifi d cop there ec.38 ,Labor Code.) PNo. ..�..h�Company t,3. Copy is filed with the city' ❑Certilied copy is here y furnishe . TOTAL C) •a CERTIFICATE OF EXEMPTION FROM REMARKS t WORKERS'COMPENSATION INSURANCE (This section need not be completed it the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of thg work for which this 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 Owner NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code. you must forthwith Minimum Setback Distances: comply with such provisions or this permit shall be deemed revoked. Front Setback from Center Line Rear Setback from Rear Prop.Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued.(Sec.3097,Civil Code.) Side Setback from Property Line Lender's Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly filled out,signed and validated,and is subject to expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. Issued by: Date Permit I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives -of this city to enter the above- mentioned property for inspection purposes. Validated by: Signature of applicant Date Mailing Address Validation: City, State, Zip C�