003256 (SFD)Building
Address 54-857 Inverness
Mailing
Address
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City Zip
.. Palm Desert 9223
Contractor
.Address .
City JZi6 Tel.
t
P.O. BOX 1504 NQ, uu4zo
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number PAANest
...2828 Legal Description
Project Description pnise, 228r P$*n 40MR
State Lic.
& Classif.. '288130
City
Lic. # 328
Sq. Ft. MG, 3142
Size • - 10�P - 58:x.
No. No. Dw.
Stories- • Units
Arch., Engr.,. _.
_.
DesignerNew
❑ Add ❑
Alter ❑. Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
_
.
Lic. #
.LICENSED CONTRACTOR'S DECLARATION
Es
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.- y.�.r
_SIGNATURE DATE
OWNER -BUILDER DECLARATIONEStlniated
I hereby affirm that I am exempt from the Contractor's License "Law for the following
reason: (Seo.. 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
the provisions of the Contractor's License •Law, Chapter 9 (commencing with <Section 7000) of
Diviston 3 of the Business and 'Professions Code, or that. he is exempt theref'r'om, 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)..
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, 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 of completion, the owner -builder will have the burden
.o/ proving that.he did not build or improve for the,purpose of sale.)°1'.
Valuation
'
q%_- 1 _ WA A _ An
PERMIT
AMOUNT
Plan Chk. Dep. ..
Plan Chk. Bal.
S° 593.44
Const.�rC%�Qv
Mech.
C
- 5 S ri
Electrical
..Ar
Plumbing1,40
50
❑ 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.)
am exempt under Sec. 8. 8 P.C. for this reason
S.M.I.
._.
- 1 �> (
Grading
Driveway Enc.
Date owner
Infrastructure
9 0041. f3
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., _
TOTAL
-
REMARKS
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, I shall not!!
• employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
cnc�
j f"�{'t<i}nclLtfs' ,hs�''r:'f.%'-t'•}'�Ic�r. b,fZ i±j;_
Date Owner
NOTICE TO APPLICANT: If, 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.
ZONE: BY: -
Minimum Setback Distances: -
Front Setback from Center Line
Rear Setback from Rear.Prop. Line
CONSTRUCTION LENDING AGENCY
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.)
Side Street Setback from Center Line
Side Setback from Property Line '
Lender's Name
FINAL DATE
_,Issued by:
Validated by:
INSPECTOR
Dates 1?f! I f3 Permit
-
Lender's Address
' . This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.:
1 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.
Validation.
City, State, Zip
HARD COPY