15704 (RR)P.O. BOX 1504 No. 15704
Building �a l lc Es re l la78-495 CALLE TAMPICO
Address A J— 8 0.0 , 8:10 , a 4 jr)8 C ra , '0
LA OUINTA, CALIFORNIA 92253
Owner
Santa Rbsa Cove 1.1:0.L.
BUILDING: TYPE CONST. OCC. GRP.
Mailing
Address 50107 Calle Vaxaoa
A.P. Number
City Zip
La Quinta 92253 Legal Description
Contractor Bryant Universal � Project Description instali new pole urethane fear
Address roof and coating over e sisting built up
3462 La Cam17aila
roo�,..
Cit Zip
FTelaltr, Springs 92260 --6022
State Lic. 365357 2293& Classif. Sq. Ft. No. No. Dw.
Arch., Engr., Size . Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the eueiness and' Professions Code, and my license is in full force and
effect. _ �,�: -•
$1GNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following $10,663.00
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 PERMIT AMOUNT
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 Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
O I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const. 3n 00
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds orsnproves thereon and who does such work himself or through his own employees, Mech.
provided that such improvements are not Intended or offered for sale. d, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden Electrical
of proving that he did not build or knprove for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors 10 con- Plumbing
strucl the protect. (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 S.M.I.
such projects with a contractor(s) Acensed pursuant to the Contractor's License Lew.) "
Grading
O 1 am exempt under Sec. B. 8 P.C. for this reason
Driveway Enc.
Date owner Infrastructure
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-copythereof. (Sec. 3800, Labor Code.)
Policy No-- _.Company
O Copy is filed with the city. 0 Certified copy is hereby furnished.
TOTAL '%30.00
CERTIFICATE OF EXEMPTION FROM REMARKS
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 person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: M, alter making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
WARNING: FAILURE TO SECURE WORKERS'COMPENSATIONCOVERAGEISUNLAWFUL. AND Side Street Setback from Center Line
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, Side Setback from Property Line
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEYS FEES. FINAL DATE aNSPECTOR \
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 160 days.
I certify that I have read this application and state that the above information is correct. Issued by: Date Permit
I agree to comply with all city and county ordinances and stale laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-. �\
mentioned property for inspection purposes. / Validated by:
Signature of applicant Date
Mailing Address Validation:
City, State, ZIp \`