003019 (RER)• j� — W OI%%!I���
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P.O. BOX 1504 No. 0030 9
Buildin 7&105 CALLE ESTADO j
Address r r Via LA QUINTA, CALIFORNIA 92253
Owner 11
:Dennis Burkett
Mailing
Address _ ..
City Zip Tel.
La Quinta 92253
t:ontractor I
Oknier/Builder
Address .
City lZip Tela
& Classif. I Lic. #
Designer
Address Tel.
CityI Zip I Sta
Licte
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 Business and Professions Code, and my license Is In full force and
effect.
_f;IATURE DATE
s% OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractoes License Law for the following
rek3on: (Sec. 7031.5,Business and Professions Code: Any city or county which reputes a
pePMt to construct, after, improve, demolish, or repair any structure, prior to its issuance also
re�ulres the applicant for such permit to file a signed statement that he 1s 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 Code, or that. he Is exempt therefrom, and the basis
for the alleged exemption. Any violation or Section 7031.5 by 'any applicant for a PemYt
subjects the applicant to a civil penaay of not more than Ove hundred dollars ($500). `
O 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, Butsness 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 of completion, the owner -builder will have the burden
of proving that he did not build or Improve for the purpose of sale.)
❑ 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 am exempt under Sec. B. & P.C. for this reason
r -
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 i1 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, 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., t, after making this Certificate of Exemption you should became
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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. 3097, Civil Code.)
Lender's Name
Lender's Address
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.
1 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 state laws relating to building
construction, and he authorlze representatives -of this city to enter the above-
mentioned property for Inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
AAPPLICANT
BUILDING: TYPE CONST. OCC. GRP.
Number 774-061-002
Description
;t Description Remodel (Den, Bath, & "loset)
iq. Ft. No. No. Dw.
Size Stories Units
New O Add Ely Alter O Repair O Demolition O
aimated valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
AMOUNT
$132.40
158.50
13.00
34.32
29.00
1.58
:TOTAL $368.30
REMARKS
uinimum Setback Distances: f
Front Setback from Center Line I
Rear Setback from Rear Prop. Line i
Side Street Setback from Center Line
\
Side Setback from Property Line
FINAL DATE
INSPECTOR
IssI�led by:
Date 4/2/37 Permit
Vaijdated by:
i
Validation:
87651
4 2 36&80 R