0012 (AR)a Cv uGv
P.O. BOX 1504 - LA OUINTA. CALIFORNIA 92253
CSM
OF
M
all - - .Iain Tho stn Som one of bw+no. ISL a .ark lea b.an waper10e11 a sbsroonaa Iw a period
of
.stn LSA ioCoin n of DD -son 7 N nit /lits mss" and fby tolmao s Co a rdd my face Undis, Wllw+nera n pin �w and 0"40
I.~ Cis UL Number
Data Conbliefo
OWIQ R' ULDEM DFCI ARAIMN 1 Ihototiy antro that 1 am exempt dons the Cdlhbador's Liemt Lw la the totloo"A"ll
reason (Sec 7.13 Bus"'ets and holessions Code: Any uty w CWMY Which teglrnas A Cam" to oonitruo' Ann.
• -Clove. 6em010h Aerep&w any sbulebaa. pot to no iswalct. Also requites rot apphures Its such perm" 10 f# A
s.pnrd slolnntm that be a 6ccnsed purswM 10 the provision of the Coniractols License Lw (Chaplet q (commFrsarq
.nn Secton 711001 Of Division I of the 11ones& and Ptclessan, C06e).or that he is taempt fh:rtltom and the bests b '
rte alltped eeeenpinas Any vroaucin at Section 70713 by Any AOphcshl 101 A perm" sub)e"s The appkuM 10 a tato
penally of for "a than live Mas"Ad dollart (i50d Y
1. as Vwnt' W the pOpr7ly. dl my employees with r&gas AS their 9014 comptthsaten. wnI do the rex►. and ase
fl'uc n, n not intended
a onued lot salt ISec. 7DM. Beards& +nit Pr oltssroro Loa The Convict In lIt lou
`F"$
ods not +7Wy ID an owner of property who build& or improves Ibeeon. and who does sur} -i :'w1 himsdf a IhouDEh�
nn own employees. pnov'Aed Thal Such imptovtmenls see not inlended a peeled I sottw n.}ep.tee, the poiymp �J
nnpiovrmVd a Sold with. one year 01 COmplehon, she owner -builder wnl have the bhabn rA ptovmp that he -did' �a�0l
build am
rpnovt bet int lha Poe 01 sahJ' I I �J
P1 at owne of Ne property. am tachnivery contracting won licensed contractors to coostttcl the project (Sec. 7W
Iness and Pt Citations Cos The Conu+aa's License Low boos not apply 10 an p"r" 0 plopeny wlobuhds
As
improv" the•eotL and who conhaGs let such pto)egs Midi + comtactor(s) "cons," Firspaid to the Eames
t ar•tse Low.) L1
" ,A t P.0 1411a[h Lonorute)
,O.1 a.p tremae. pnNltT Swt. _ —�--. •_-.,, , ..
Date O.net—
WO,,n:IRS COUF1NSAIION DECLARATION I he.eby itlurr• Inal I r.avc'eoftemlicair IL abnsCt1i to self-insun t. w a
sariiLUle of Wo'•ni Compensation Insuianct. or a CHbfitd copy
Policy No
Company
D Ceetdeo copy is h.eteby lutntshod
ID Certified copy a hied .esti the County Buao.nq InSDecfion Department a Courcy
Appinanl
6"3 -1 Y''`)`1 cw Qv' w
CERIlfiCATE OF EXIMP11DN FRDM WDMFIS' CDMPENSAI'ON MSLOANCE TM &octan roved lot be omplsld R Ills
pelma a 103 oft bundled 0110010 less looney that n Ill pentor0ena of The wort flat ste .etlhb Coast" a a►ueE.1
snail not employ Any pawn rn any mover Ao a$ 10 become Aublact 10 fie Waken' Compafsstron Lot W California
Data Apo"
MOTILE TO APPLICJ•N1: N. ane shaking fhb Consistent 94 EaeinpliwL yoo Should becen wb1+ct to fon Ww%gW
Compensation prov siaa of the Labs Colt. you mull tor'ow.Mh oomph' with Sigh po+arou an this perm" Shea be
deemed tarOkad -
DIVISION OF MDUSTRIAL GAFETT PERMIT CERIIFICAt1011: •:.s.
m91(��
1 booby certify that no teuvolhon Ins (S) amort sadist 600th EMs' .hclh " b A portaneouiod to desce d. ,am be
a an onnection with work authorized by this pas and that no bundling structure. wnotdrnp. 1alsmon. a
demolition A damanthng Incites. win be more than tinny -all fast h. (Chep 7! Grp L Ant Sec 711. Tate l
CA.CJ
PAs owner -builder, l will not employ Anyone to do work .whiclh would tequila pemmll bom the Dimlon of Industrial
ry. as noted above. unless such gelatin has A pwmn it do such work hem " d""Jioa
j3 Dr1' of (nL sural SiTily rm" No.
s Appi"M
CONSTRUCTION LENDING AGENCY: 1 hereby anam that Itro Is a eonsnuclion lending agency for the peAwmanu of
' 41y_wdlk to, which Ihsrer is awed U.
70Q7. tn.:J.
11
[1JJnde t NarM
\Le�he.t1/<21I S I
T[enry 1841 have teas abbe applration and slate Inst rue above inldlmalion is eonect. t &gide to comply with An
oily and county ordinances and %tate taws te4lmp to Wcdnip construction. and Fluent, sumonze tepgftntafivts of
•.•this county to onto upon the above-mentioned propeny too inspection outposts.
S'gnalme of Applicant ov Agent Date
CERTIf ICAiE OF COMPLIANCE AND AUTHDR1ZAI:DN OF EN:RT. I celity I have read Inn application and State not IM
Inloln.af.pn given IS careen I agree so Comry Irl ]II iJale -i.n unly md.nancts nelabng to building con
sit u[fion and autno,ue ] rtpresenialive of IN `v/ et�l1� ;%/rent of huil0mq and Salty to emr' apo^
Int ptnpcny los whCn I have applied Ion this pe'mlflot IM p rpose of mating inspections.
Geputrrirnl. Signature of Appiican) a Ape. .
AP N7 AAM (L. F. MN
ACTRESS
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ADD -ESS
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PHONE • IICNC
ARCiING FIRM NAME
ADDRESS
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PHONE •
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END
SIDE
Punt AnpbcantlAoenl Name
APPL"MT a
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PS
DATE
Y
vie a &�/i oe�l'I
a-27;/`t?F
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TOTAL
FEE
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IPA 9 10