003259 (SFD)Building
Address
Owner
Mailing
Address
City
PAIT!
Contractor
Address
4
P.O. BOX 1504
78-105 CALLE ESTADO
54-897 IYlilermess LA QUINTA, CALIFORNIA 92253
Zip Tel.
.. . 22s3
Zip .. Tela
No.. 003259
BUILDING: -TYPE CONST. OCC: GRP.
A.P. Number PM wAst-
Legal Description -
Project Description ll hAnA 22R: PTIAn 10MV
State Lic.
City
& Classif. 2R�
Lic. #
Sq. Ft.- DWG 3142
No. 'No. Dw.
Arch., Engr.,
Size ,� r n I
Stories _ Units
.... _
• Designer
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
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'
^n .
effect. f
k'
SIGNATURE - DATE-
^ ' .^ OWNER -BUILDER DECLARATION
Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following
SS �! Ft
1
reason: (Sec; .7031.5,Business and Professions .Code: Any city or county which requires a
'! s
,, 6 V0
pemto construct,, after,. 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, of that. he is exempt therefrom,' and the basis
'for the alleged exemption. Any violation Section 7031.5 by 'any for
-
Plan Chk.: Dep.
of applicant a permit
subjects the applicant to a civil penalty'of not more than five hundred dollars ($500).
O I, the
Plan Chk. Bal.
'
593.44
as owner of 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
Cor1St.
Professions Code: The Contractor's License Law does not apply to- anowner of property who
73�
builds or'improves thereon and who does such work himself or through his own employees,
that' improvements intended.or
Mech• -
s7�i�
55.'•:.70
provided such are, not offered for sale. If, 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 Improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
Plumbing��tf
511
slruct 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
S•M•1.moi.{
- such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) . -•
Grading
❑ I am exempt under. Sec. B. & P.C. for this reason
Driveway Enc.
Date owner
Infrastructure
2.000.00
WORKERS' COMPENSATION DECLARATION
hereby affirm that 'I have a certificate of consent to'selfzinsure, 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. . O Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE -
(This section need not be completed if the permit is for one hundred dollars ($100) valuation ^
or less.) -
I certify that in the performance of thg work for which this permit is issued, I shall not - ,fF` it ,k?� y(j$ T � i--�'r tisk�r A-112
- employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date' Owner
NOTICE TO APPLICANT: If, 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.
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 it work thereunder is suspended for 180 days.
I 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
HARD COPY
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 INSPECTOR
Issued by: Date -2f /A7 Permit
Validated by:
Validation: