15248 (BLCK)TA
f,-
15's-45,935,99-5No. 15248
P.O. BOX 1504 •
Buil n r96"') a 78-495 CALLE TAMPICO a
Address LA QUINTA, CALIFORNIA 92253
Owner
l.t~_:•3:u7'y YfC:Br': _o
KA,,;,; BUILDING: TYPE CONST. OCC. GRP.
Address. 11-35 SD-ath "DA St:.o,
City Zip Tel.
San v+-_'1:xnardino, CA 92408 (909)381-600"17
Contractor
S ajltr::
State Lic.
& Classif. R 314473
Tela
Lic. # 21 u 0
Arch., Engr., _R
Designer rayik Gon_-a.les & A550ciateE
)Mff East ':hapman Ave. Te%714) 532-687
City Zip State
Orange, rCs� 82666 Lic. III
LICENSED CONTRACTOR'S DECLARATION
Waffirm that 1 am licensed under provisions of Chapter.9 (commencing with Section
of Division 3 of the Business and Professions Code,and my license is in full force and
fact _
,SIGNATURE DATE
OWNER•BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Buskfess and Professions Code: Any city or county which requires a
permit to construct, alter. Improve, demolish, or repair any structure, prior to �hs 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 g (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 civti penalty of not more than rive hundred dollars (5500).
❑ 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 Trot intended or offered for sale. If, however, the building
or improvement 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 operty, am exclusively contracting with licensed contractors to con-
struct the project. 7044, Business and Professions Code: The Contractor's License Law
does not apply to owner of property who builds or Improves thereon, and who contracts for
such projects it a contractors) licensed pursuant to the Contractor's License Law.)
O 1 am exerpbtonder 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 Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No.. Company
,OJBopy is filed with the city. ❑ Certified copy Is hereby furnished.
is
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 thg work for which This permit is issued, 1 shall not
employ any person In any manner so as to become subject to the Workers' Compensation
Laws of California
Dated Owner
NOTICE TO APPLICANT: H, 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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000); IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.'
This is a building permit when property filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 160 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
A.P. Number
Legal Description Trod 26153
Project Description 150 1. f . Of 6' hJgh gardEert
privacy wall
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation' �' 1 �t ► 50 0
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
198.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
j9 P, 0 +,
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
FINAL DATE •INSPECTOR
Issued by: Date • Permit c �\
Validated by:
Validation: \