04-6799Ti4
� Y- 6 �9
P.O. BOX 1504 APPLICATION ON
Building3 A� i 78-495 CALLE CALIFORNIATAMPIO
Addie ��L.A OUINTA, ORNIA 92253
STS A►J16 Crc 6L.
Mailing
Address _ 50 2
City Izip ITO.
State Lic. City I
& Classif. I Lic. #
Designer
Tel.
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) of
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
WORKER'S COMPENSATION DECLARATION
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 ($100) 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 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.
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
WHITE = BUILDING DEPARTMENT
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number —r7-3 ' 0¢4 . o ll
Legal Description 60-7- /C 7 ! —
Project Description Vim' 4L_
a'1ifLi. % Ury tv— Z 44
Sq. Ft. / No. I No. Dw.
!
Size 94M Stories l Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
Ol< %'o i JS
3yk,,
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. �—
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
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
1r,
FINAL DATE
1r,}` - ---?INSPECTOR 3
by:
APermit
Issued
Date- L,11,
Validated by:
C=s�^'T1 D+_�
Validation:
YELLOW = APPLICANT
PINK = FINANCE