002380 (ELEC)P.O. BOX 1504 No; 0023$0
Building 78-105 CALLE ESTADO
Address 54-900 Imems>3 LA QUINTA, CALIFORNIA 92253 !
Owner _.. .
Mailing BUILDING: TYPE CONST. OCC..GRP.
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Address
_ri-�owi +f n*-ry frinh nrivp A.P. Number
CityZip Tel.
M .DeSe� .. .92ZO -. 568-2828 Legal Description
• Contractor Project Description W+ ` T - - thwia-S 7 $ A
MU N gupadlnd
Address -
Sam
'CityZip - Tel:'
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State Lic. City
& Classif. 288230 Lic. # 328=Sq. Ft. No. No. Dw.
Size Stories Units
Arch:, Engr.,' -
Designer New Z Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State cm 280 Meter pole with 20 te=xt. pY,,rag
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 anC Professions Code, and my license is in full force and '
effect.. f
SIGNATURE" A DATE _
OWNER -BUILDER DECLARATION Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following
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 role a signed statement that he is licensed pursuant to s. PERMIT AMOUNT
the provisions or the Contractor's License Law, Chapter9 (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 (5500). Plan Chk, Bal.
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 Const.
Professions Code: The Contractor's License Law does not apply to an owner of property who '
builds or improves thereori and who does such work himself or through his own employees, McCh.
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 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
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.I-
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
O. 1 am exempt under Sec. B. & 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 copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with.the city. ❑ Certified copy is hereby furnished.
TOTAL 135.00
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
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 ZONE: BY:
'subject to the Workers" Compensation provisions 'of the Labor Code, you must forthwith Minimum Setback Distances: `
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lender's Name
Lender's Address FINAL DATE INSPECTOR
This, is a bullding permit when properly filled out, signed and validated; and is subject to FINAL
expiration if work thereunder is suspended for 180 days. - LSP—Gi
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 state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes. r„ r Validated by:
Signature of applicant , A'( 1i . _ Date '^ f
Mailing Address /" `^" Validation:
City, State, Zip
A 5 6 5 4 5 23 a 35,00 CK
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