002232 (SFD)44
P.O. BOX 1504 No.. 002232
Building 78-105 CALLE ESTADO
Address 54-994 IfWeITAM LA QUINTA, CALIFORNIA 92253
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Mailing
Address 75-005 tXV M.
CityZip FTe
Contractor
. & MirtimCe Mid lZald
Address . . .
Sam
Zip Tel.
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
568-2$2$ Legal. Description
Project Description �C•>,i� WIM RIAN 40 0
State Lic. City
& Classif. 288130 Lic. # 328 _
Arch Ph—
_..�..1
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 Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
f ` "
OWNER -BUILDER DECLARATION
Fhereby affirm that I am exempt from the Contractors 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 file a signed statement.:that' he is licensed pursuant to
theprovisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
'..Diviston 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
subjects the applicant to a *civil penalty of not more than five hundreddollars($500). ° "-
❑ 1, 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 iheieon 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
or improvement is sold within one year or 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 con-
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 contractor(s) licensed pursuant to the Contractor's License Law.)
0 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm'that I have a certificate of consent to self-ihsure, 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.
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 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
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.)
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. r
Signature of applicant - ` '''/ Gr Date
Mailing Address
City, State, Zip
HARD COPY
3142
Sq. Ft. No. No. Dw.
Size Stories - Units
New 1% ' Add ❑ Alter O• Repair ❑ Demolition ❑
.A
Estimated Valuation 349.00
PERMIT • '
AMOUNT
Plan Chk. Dep.
Plan Chk.. Bal.
5".19
Const.
£78.£0
Mech..
j}(
Electrical
1".65
Plumbing
140.50
13-.$3
Grading
Date Permit --
Driveway Enc.
Infrastructure
2,000.00
A51.13
4 8 3586.17 R
TOTAL
3,580.17
..'REMARKS
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
4-7--86.
Issued by:
Date Permit --
Validated by:
Validation:
A51.13
4 8 3586.17 R