002088 (BLCK)Building
Tel.
Address►
City
Owner
State
Lic. # _
B ., 1c. � waa llz
VdIlawknM&A 11&. MA68,
Mailing
Address
7 5-0
City
w I hereby affirm that lam licensed under, provisions of Chapter 9 (commencing' with Section
7000) of Division 3'of'the
tBusiness and Professions Code, and my license is in full force and
effect.
Palm
r4pstpx
Contractor
-
• • 'PERMIT ' AMOUNT
U
Address
i�t�rrtss
City
,
Electrical
State Lic.
& Classjf. 288130
Arch., Engr.,
Designer
""f Of aw
P.O. BOX 1504 NO. O 2 0 8 8
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
�R Legal Description
Project Description Vii: W011
Zip ITel.
Tel. - -
s saw.
City
Lic. #
Sq. Ft.
Size
New E
No. No. Dw.
1,ft.. Stories. Units
Add ❑ Alter ❑ . Repair ❑• Demolition ❑
Address
Tel.
City
Zip
State
Lic. # _
B ., 1c. � waa llz
VdIlawknM&A 11&. MA68,
LICENSED CONTRACTOR'S DECLARATION
^
w I hereby affirm that lam licensed under, provisions of Chapter 9 (commencing' with Section
7000) of Division 3'of'the
tBusiness and Professions Code, and my license is in full force and
effect.
SIGNATURE SA`4.<R+'"" "'Y" - DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
. reason: (Sec. 7031.5,Susiness 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
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 therefiom, 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 ornot 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. (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. If, however, the building'.
Estimated Valuation 1
,-_
• • 'PERMIT ' AMOUNT
'
Plan Chk. Dep..
Plan Chk. Bal. U8.37
^
COr1St. "7-50
Mech.
,
Electrical
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.)
Plumbing
❑ 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.) ,
❑ I am exempt under Sec. B. ti P.C. for this reason
_
S.M.I. 224
Grading
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
0 Copy is filed with the city. • ❑ Certified copy is hereby furnished.
TOTAL 323.01
CERTIFICATE EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
REMARKS
-
(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 theLaborCode, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Ihereby 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 Street Setback from Center Line '
Side Setback from Property Line
Lender's Name
FINAL DATE INSPECTOR
Issued by: Date 26-8(Permit
Validated by:
Validation:
A4425 2 26
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 property for inspectiori'purposes.
Signature of applicanAkl!t%\'VN, (I �lRd � f ♦, Date
Mailing Address—K T t �. x 1
City, State, Zip `
HARD COPY