08587 (SFD)ARROW PRINTING. INDIO. CA 2000 7/00 7770e1-cl
4 4a QUWCV
P.O. BOX 1504 N o R
Building 78.105 CALLE ESTADO
Address 48-480 San Vincentie LA QUINTA, CALIFORNIA 92253
Owner
Tom Carney
Mailing BUILDING: TYPE CONST. OCC. GRP.
Address 33821 Blessington Lane A.P. Number
City Zip Tel.
San Juan Capi trano 926751714/ Legal Description
Contractor Project Description S _F _ T) _
Address
ty jZip I Tel.
State Lic. I City
& Classif. Lic. III 1
Arch., Engr.,
Designer C
.Q. Design
Address Tel.
14 04L -134U
City ZipState
Costa Mesa 92627 Lic. q
LItree Red CONTRACTOR'S DECLARATION
I herebyy affirm that I a aee�tl under provisions of Chapter 9 (commencing with Section
7000) of Divisiqp-3,ol uslness and Professions Code, and my license is in full force and
OWNE - UIL R DECLARATION
Ihereby affirm that I am exem m the Contractors 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 rile a signed statement that he is licensed pursuant to
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
ror the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
Subjects the applicant to a civil penalty or not more than live hundred dollars ($500).
O 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, Buisness and
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,
provided that such improvements are not Intended or offered for sale. it. however, the building
or improvement Is sold within one year of completion, the owner -builder will have the burden
of proving that he did nor build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
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
such projects wish a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Seca B. & P.C. for this reason
Date Owner
.. WORKERS' COMPENSATION DECLARATION
Ihereby 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
G Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If the permit is lot 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
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions of 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 when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify tnat 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 apoGcant _ _.—.—_.—_..Date_ -.__—
Mailing Address_ --------- -----------------
08587
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line—'
_ Side Street Setback from Center Line
Side Setback from Property Line_
FINAL DATE -- INSPECTOR
Issued by:—
Validated-by:
Validation: _
Date Permit.
Sq. Ft.
Size 4400
No. No. Dw:
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
400 000.00
PERMIT
AMOUNT
Plan Chk. Dep.
250.00
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
250.00
REMARKSi
1" ? CASH ZIAL 1 yG ` • V 10
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line—'
_ Side Street Setback from Center Line
Side Setback from Property Line_
FINAL DATE -- INSPECTOR
Issued by:—
Validated-by:
Validation: _
Date Permit.