15704 (RR)T
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P.O. BOX 1504
Building Callc, E sir: -11.a 78-495 CALLE TAMPICO
Address�'—S 0 3 . R 2-' it , u F, , 8 G 3 LA QUINTA, CALIFORNIA 92253
No. 15704
Santa Rosa Cove li.O.F,.
BUILDING: TYPE CONST.
OCC. GRP.
Mailing
Address 501107 Cal -le Oaxaca
A.P. Number
City
Tel. 'La
17i'�92253
Quint,-.
Legal Description
Description Instal?
new poly urethane frarm
Contractor ryart Universal
roof and coating over exsistirg built u-
Address
3462 La Camparla
r
ro�-�i J. e
Cit
alr: S?rings
Zip
94-2.60
Tela
320--6022
'
State Lic. 305357
& Classif.
City 2293
Lic. #
Sq. Ft. No.
No. Dw.
Size Stories
Units
Arch., Engr., -
Designer
New O Add O Alter 0 Repair O Demolition O
Address
Tel.
City
Zip
State
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 � J' -
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, atter, 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 Lew, 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, 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. H, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
0/ proving that he did not build or improve for the purpose of sale.)
Estimated Valuation
$10,803.00
,
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.$30.00
Mech.
Electrical
Plumbing
❑ 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 with a contractor(s) pcensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
S.M.I.
Grading
Driveway Enc.
Date Owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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.)
Polis No:- `�
Y -.Company
❑ Copy Is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
$30.00
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed H 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 �erson In any manner so as to become subject to the Workers' Compensation
Laws of Cali ornia.
Date Owner
NOTICE TO APPLICANT: tt, 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. '
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 if work thereunder is suspended for 180 days.
1 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
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
'v
FINAL DATE ANSPECTOR
Issued by: Date Permit
Validated by: \�
Validation: