003454 (ELEC)P.O. BOX 1504 N o'. 003454
Building 78-105 CALLE ESTADO
Address 54493 �. `waRms LA QUINTA, CALIFORNIA 92253
Owners . , .._ .
SMISE co
Address 75-005 COMMY CLM DRM
City Zip Tel.
._ P LK DESERT 92260 564-6716
Contractor
SATIOM LAND AM MORTGAGE
.Address.
Zip - . - ' Tel. .
State Lic. I City
& Classif. 255130 Lic. # 328
Arch., Engr.;
Designer
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'Ptrofessions Code, and my license is infull force and
effect.. // v r 1'# 1 /-1 t r'7
011 '.1 —J X a i' ,Y .' GATE
OWNOR 61.! LDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason:, (Sec. 7031.5,8usiness 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 file a signed statement that he is licensed pursuant to
ithe 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 Dy 'any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred'dollars ($500).
O I; as owner, of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec.. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees, .
provided that such improvements are, not intended or offered'for sale. ff. however, the building
-
or improvement is sold within one year of completion, the owner -builder will have the -burden
of proving that he. did not build or improve for the purpose of sale.) '
❑ I, as owner of the property, am exclusively contracting with licensed contractors to torr
struct the project. (Sec. 7044, Business and Professions Code::. The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the. Contractor's License Law.)
O 1 am exempt under Sec.. B. & P.C. for this reason
LDING: TYPE CONST. OCC: GRP.
Number P!G& WEST
al Description
lett Description EHME' 22$ C AMN A
HE= PEDESM
. .. . 1r* ?0IN -AAA 03
Sq. Ft. No.
Size - Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Lstlmatea valuation
PERMIT
Plan Chk. Dep.
Plan, Chk. Bal
const.
Mech.
Electrical '
Plumbing.
S.M.I.
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 copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
O Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff 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: If, after making this Certificate of.. Exemptionyou 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.
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.)
Lenders 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.
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 properly for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
HARD COPYI
TOTAL
REMARKS
AMOUNT
.u'
22.54
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 10/16/8,Permit
Validated by:
Validation: