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04-7010 (SOTB)57001 Madison St 04-7010 - P.O. BOX 1504 APPLICATION ONLY Building 78-495 CALLE TAMPICO ]' -- LA QUINTA, CALIFORNIA 92253 _ ,I Address _ "' Owner GGL/ BUILDING: TYPE CONS1"'W GRP. Mailing r 775- 10D 60 Address A.P. Number ty Zips 2 TT. 1. Legal Description ontract - J Project Description r n ° i CA_ te- :ftJkL S Address q l a 0 V ft i i D zipq 1-7 /, 1 P9 37G 11-2 0 State Lic. City & Classif. Lic. # Arch., Engr., Designer Aclaresf 7 14,q 7 S 91L,Av k- t c;l _+( ,1 AN k"U 1 L4 lip 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 is in full force and effect. SIGNATURE DATE OWNER -BUILDER DECLARATION 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 requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor'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 for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit 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 do the work, and the structure is not intended or offered for sale. (Sec. 7044, Business and Profes- sions 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, provided that such improvements are not intended or offered for sale. If, however, the building or im- provement is sold within one year of completion, the owner -builder will have the burden 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 construct 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 such projects with a contractor(s) licensed pursuant to the Contractor's License Law) ❑ 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKER'S 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. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (3700) valuation or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to Workers' Compensation Laws of California. Date Owner NOTICE TO APPLICANT.' If, after making this Certificate of Exemption you should become subject to the Workers' Compensation Provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. 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, Civil Code.) Lender's Name Lender's Address This is a building permit whenproperly 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. 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. Signature of applicant Date Mailing Address City, State, Zip Sq. Ft. U Size New Add ❑ ,+- O rwai No. No. Dw. Alter ❑ Repair ❑ Demolition ❑ I Estimated Valuation r /©, !/ ,-v,f-s I PERMIT AMOUNT Plan Chk. Dep. 010r 00 Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: r Minimum Setback Distance ,d0„4A_ FINAL DATE. Issued by:_ Validated by: Validation:— WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE Permit