SPIN (0004)V,4
cE'
OF 'J } P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253
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This permit Oecomn void If-rfirk not mmmencee-.eitnn Tp Days Nom date of issoaxe. OR. n work has been Suspended Or abandoned for a period o1 IID days
LICENSED CONTRACTORS DECLARATION. 1 hereby atlem that 1 am bcensed under provworu of Chaplet 9 (Commencing
with Section 7= a1 Division 7 of the Business aro ProfesMoru Code. and my license et in full force and effect
lrcarna Class
Lic. Numbs
Dail Contractor
OWNER-BIALOER OECL ARATIDN. 1 hereby affsm that I am exempt from the Contractors License Lw for the following
reason (Sec 7031.. Business and Professions We: Any city OF county which requires a permit to construct. aha.
Improve. demoluli Of repair any structure. prow to its Issuance, also requires the applicant for such permit 10 fit a
Signed stelement the, he is licensed pursuant to the provisions of the Contraco's license Lw (Chapter 9lcommenang
with SeC1.11 70001 of Division 7 of the Business and Piolesslons Code) or that he is exempt therefrom and the basis fa
the alleged exemption Any violation of Section 7071.5 by any applicant for a permit subjects the applicant to a civil
penally o1 nor more than I've hundred dollars f6500).):
O I. as owner o1 TM property. at my employees with wages as their sole compensation. will do the wait, and the
suuclwe Is not Intended or citified tot sale (Sec. 7044. Business and Profess-orts Code: The Contractor's License Lw
Oohs not apply to an owner of property who Wilds or Improves thereon. and who�oes such wwiA ltimsilf oi�lhioIt i
his own employees. provided Ihai such improvements are nor intended Or filleted Iw-Satex Il.however, the buirdmg orJ
Imwovemeni n son within one year of completion. the owrtr•Wildet will have the burden dl proving that he did nal
Wird of improve for the purpose of sale.). 1 1
P1. as owner of the properly. am exclusively contracting with licensed contractors to construct the project (Sec.70M.
U.: and Professions Coot The Contractor's License Law does not apply to an owns df property wrobuilds or
Improves thae0nl and who contracts lot such projects with a emtnaclor(s)' licensed purspant to the'-Conlra
License Lw.) L.
�1
O 1 am exempt under Sec. B. b P.C. IAllach Ceniflcare)
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of Consent to setbinswe. or a
cerliIscale of Workers' Compensation Insurance. or a eenitied copy lhereol (Sec 3800. Lab. C.).
Policy No. Company
Certified copy is hereby furnished
O Cerlrired copy Is tried with the County BuriOmg Inspection Department or County Department.
Date Applicant
APPLICANT NAM (L. F. I) /
ADDRESS
CIT YICOV MUNITY/STATE/ZIP
JOB SITE A DRE SPACE
CIT Y/COMM.UNITY/STAT E/ZIP
BOK I
PAG
PRL
C
TWN
SING
SE
S
TRACT
3
P Un
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lOT
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MOD
SB
TRACT NAME
OWNER NAIAE (L. F. MI)
CONTRACTOR -FIRM NAME
ADOPESS
CITY ICC-'M'J .ITY!STATE21P
PHONE •
LICNC
ARCIEN—. FIRM NAME
ADDRESS
CITY!COMMUNIT Y:STAT F;ZIP
PHONE •
LICNC A
USE OF PERMIT
BL
ZON
FSB
SSB
SSB
RSB
OFC
ZCNE ORD a
LOT SZ
END
SIDE
,a35/
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This sactan need rot be completed m the
permit s for ort hundred 111100) or less I certify that in the performance of ON wort for which this permit u issued. I
snail nor employ any person m any aan/ne�r so as to become s� 1 t/0 �O/IA►War Compensation laws of Eamorma.
Date7Y � �r% r+fi5 6 Applicant �y •H•• /t
NOTICE TDA PLICAL : h. She'_kI1i this Certifrcale/Of r Ea %U N be= N Subjod IO the Worr{
ke'
Compensation pro.aions of Int Labor Code. you must forthwith comply with sudorprovisions w this permit Shan W
deemed revoked
DIWSION W INDUSTRIAL SAFETY PERMIT CERTIFICATION:
D 1 hereby coliy That no excavation live (5) or mon feet in depth into which a person Is recurred to descend. won be
made In connection with work authorized by this perink and that no building structure. scaffolding. falsework, Or
demolition Of dismantling Thereof. will be more than thirty-sh (35) les high. (Chap 31 Grp 2 Art 2 Sec 341. Title B.
C.A.C.)
As ownerbuilder. 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 Pam" to do such work from that division,
'o'D.-Isi1 f;&l,@-SiTefy 'nmd No.
Dike Applicant
t CONSTRUCTION LENDING AGENCY: I hereby affirm that there it a construction lending agency for the performance of
'Vie.wwk tai Which trusrpt1eirit is rasped (Sec. 3097. Civ. C.).
!
44nda'6 Nanta
,IrLehaer'sln°/AONest
cMi1P al 1 have real This application and stale that the from information is coned. 1 agree to comply with all
oily and county ordinances and stale laws relating to building construction. and huetty authorize representatives of
This county to emu upon flit above-mentioned propeny for inspection purposes.
Signature of Applicant at Agent Dale
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify I have read this application and state that the
information given is cared. I agree to compy witch all slate Sus n lanky ordinances relalrng to building con
struction. and authorize a representative of Ihe(;yEriyy oyG�� ja69,pent o1 Building and Safety to enter upon
the property lot which I have applied for This permiyfor the p ipose ofLm7aking inspections.
Signature of Applicant or Agent Dae
Print Applicanl/Agent Name
APPUPRMT0PS DATE '
CCO e/ %a
3
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TOTAL •
FEE
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