0310-312 (SFD)Building
Address
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Mailing
Address
City
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TU LC F P.O. BOX 1504 APPLICATION ONLY
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5 , CALIFORNIA 92253 01 - 3ti
Zip
Address
City
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Lic. #
dIC:ENED COVIRACTOR'S DECLARATION
I herebgffI!m that I rn I e, r vl�ll 0 a Ing with Section
7000) of Ivisiono— rof s e, a`ndernn9yj=:r1,cS inflforlanA
effect.
t3CWATURE I&, Z�11.r_,C_l lyz
24 -4 -MILL
OWNER -BUILDER DECLARATION r
I hereby affirm th I I am exempt from the Contractor's License Law for the following
reason: (Sec, . 7031.5,Lsiness 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 La., 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 th
ie 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 hundraddollars ($500).
1-11 1 as owner of the property, or my employees with wages as their sole compensation, will
do ihe 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 of 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
of improvement is sold within one year of completion, the owner-builde.r will have the burden
of proving that he did not build or improve for the purpose of sale.)
I 1 1, 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 with a contractor(s) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec.—B. & P.C. for this reason
Date —Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's ComEWnsation Insurance, or a ce 0� ;dV thereof. (Sec. 3800, Labor Code
4 7"
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Policy No� pany
ri Cof�y I�s fil'edwifh t5hillcity. 0 Cer ifie'd copy i's Ver;"b;M�11fistfed—
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 th� w ork for which this perm it is issued, I shall not
empi oy any person in ny manner so as 0 become subjec to the Workers' Compensation
Laws of California.
Date—Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to th 9 Workers' Compensation provisions of the Labor Code, you must forthwith
comply with Such provisions or this permit shall be deemed revoked.
I
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. 309 7. Civil Code.)
Lender's Name—
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expi ration it 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
con s truction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant —Date—
Mailing Address
City, State, Zip
V
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number I, / Ir
Legal Description I -or ?JQL- /-06/
str
Project Description IN
(001mer
Maw- (
Sq. Ft. No. �56 No. Dw.
Size Sto Units
New 0 A/d 0 Alter 0 Repair 0 Demolition 0
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.L
Inf "Grading r%
Driveway En
rastructu
CIT
L_F_
TOTAL
REMARKS
OF LA QUINTA
AMOUNT
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: Date—Permit
Validated by:
Validation:
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE