002577 (ELEC)4
P.O. BOX 1504 No. 002577
Building 78-105
78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner
Lmdumt land
Mailing
Address P.O. BLOC 1000
CityZip Tel.
. Tom. Z -,9n53
Contractor
T?q—
Address
Sq=
City ' Zip y Tela
State Lic. City
& Classif. A1191A Lic. #
Arch., Engr.,
Designer
Address Tel.
City xZ Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed `under provisions of Chapter'9 (co
7000) of Division 3 of the Business and Professions Code; and,my lic
effect. 1a . . -0 _ +r I . -IF
BUILDING; TYPE CONST. OCC: GRP:
A.P. Number
Legal Description
Project Description
113 _ Sq. Ft. No. No. Dw.
Size Stories Units
t. New (]k Add ❑ Alter ❑ Repair'❑ 'Demolition. ❑
100 as meter peftstal fxxr
nencing withSection -
se is in full force and r,
SIGNATURE �. .� xt.o r•.v ... _ �.. DATE .
OWNER -BUILDER DECLARATION
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 conshuct, 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
Estimated Valuation
'
1_
._ PERMIT '
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 Is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section •7031.5-.by:'any applicant for a permit
Front Setback from Center Line
..Plan Chk. Dep..._
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. jSec. 7044, Buisness and
Professions Code: The, Contractor's License Law does not apply to an owner or property who
Plan Chk. Bal.
COnSt.
Mech.
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
Electrical
or improvement is sold within one year of completion, theowner-builder will have the burden
of proving that he did not build or improve.for the. purpose of sale.) .
Plumbing
O I, as owner of the property, am exclusively contracting with licensed contractors to con-
- struct the project. (See. 7044, Business and. Professions Code: The Contractor's' License Law
S.M.I. '
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.)
❑ I am exempt under Sec. B. 8 P.C. for this reason
Grading
Driveway Enc.
A 6 5 4 8
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 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-__LOwner
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 forlhwith
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. 309 7,. 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 if work thereunder is suspended for 180 days:--
I certify that 1 have read this application and state that'.4he above information is correct.
I agree to comply -with all ciy and county ordiriances,and state laws relating to building
construction, and hereby authorize representatives -of, this 'city to enter, the above-
mentioned property for inspection purposes. /J f
Signature of applicant
Mailing Address t
City, State, Zip -1 '
HARD COPY
TOTAL
REMARKS
A AMOUNT
-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 9-16" ermit
Validated by:
Validation:
A 6 5 4 8
9 16 2256 CK