002551 (BLCK)Building
Address
Mailing �+
Address 75-005 i 14d.31b Drima
City Zip Tel.
m'i xt 922M 56$
Contractor
Nail. I.' ram and TAnd
Address ..
>a
City Zip Tela '
State Lic. City
& Classif. , ;1 ', f Lic. #
Arch Engr
P.O. BOX 1504 NO. 002551
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
•2828 Legal Description
Project Description JIM%A_ "WPWI h 7 P
Sq. Ft..
Size
No. No. Dw.
Stories Units -
Designer
New lit Add ❑
Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION rY
• 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.
SIGNATURE * 1 DATE
'
t OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the contractor's License Law for the following
Estimated Valuation
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 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; or that. he Wexempt therefrom,- and the:'basis
for the alleged exemption. Any violation Section 7031.5 � by any for 'permit
Plan Chk. Dep.
- - '
of applicant a
subjects the applicant to a cNil'penalty'of not more thanfive hundred dollars ($500). • "
_
Plan Chk. Bala_
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- • '�
.❑ I, as owner of the property, or my employees with wages as their sole compensation, will
I 9 _ An
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
25f;IIn -
builds or improves' thereon and who does such work himself'or through his own employees,
Mech,
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.) • .
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
Plumbing
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
- S.M.1.
• such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) •- -
Grading
❑ I am exempt under Sec. B: ti P.C. for this reason
Driveway Enc.
Date Owner
Infrastructure
WORKERS' COMPENSATION DECLARATION
Thereby 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
A7�_A
CERTIFICATE OF EXEMPTION FROMREMARKS
'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 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 Exemption you. should become
ZONE:
BY: '
subject to the 'Workers'" Compensation provisions of.the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
Minimum Setback Distances: - '
Front Setback from Center Line
I,
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 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.
Issued. by:
Date 03-7—RA 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.
Validated by:
Signature of applicant �� l ` r Date 1
Mailing Address 1 a '
Validation:
City, State, Zip
Ab28U
9 3 4245 ER
HARD COPY