15704 (RR)4
P.O. BOX 1504
Building 'A le E str"11,1 78-495 CALLE TAMPICO
I Address LA OUINTA, CALIFORNIA 92253
Owner
I cxnta Ft05a COVE:
Address 5010-1 Calle. Oaxaca
City Zip Tel.
La Quint. 9.2253
Contractor
Bryant Universal
AddressI
3 4 6 L La Cc3,"ia �79Ilot
t'li: Llp I el.
a1t�t Springs 92260 320--6022
State Lic. 365 357 City 2233
& Classif. Lic. #
Arch., Engr., I
Designer
Address Tel.
City IZip I State I
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, after, improve, demolish, or repair any structure, prior to its 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 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Cade, 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 (E500).
❑ 1, 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. If, however, the building
or Improvement is sold within one year or 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 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 contractors) licensed pursuant to the Contractor's License Law.)
0 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 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 8 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.
Date Owner
NOTICE TO APPLICANT. fl, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions or the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
c
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,(X10), 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 properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that 1 have read this application and state that the above Information is correct.
I agree to comply with all city and county ordinances and slate 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
No. 15704
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number
Legal Description
Project Description Install new poly urethane f an.
roof and coating over exsfst-ing built up
root .
Minimum Setback Distances:
Front Setback from Center Line
Sq. Ft. No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
ANSPECTOR
Issued by:
Date Permit
.Validated by:
Estimated Valuation
$10,063.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
art , 00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
'Z310 . 00
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
ANSPECTOR
Issued by:
Date Permit
.Validated by:
�\
Validation: