002212 (ELEC)4
P.O. BOX 1504 No. 002212
Building 78-105 CALLE ESTADO
Address 55-6 InVeneSs LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address 75-005 t txy Club )rte.
CityZip Tel.
P! ,+Ls,L' 568-28
Contractor
•% Mq'. and Ubd
Address ....
State Lic. City
& Classif. Lic. # y {l
Arch., Engr., '
Designer
Address Tel.
City Zip State
. . . . Lic. #
y LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) off Division 3 of the Business and Professions Code, and my �lYic'ense is in full force and.
'SI
effect. 'h.'.�`f : mow,., irri a •_i• :.�✓ crlt..•••_r t ifrf�/�.
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
Legal Description
Project Description
200 moi. tMVR bc*xw. males
Sq. Ft. No. No. Dw.
Size Stories Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
SIGNATUREI. DATE
ZONE:
' OWNER -BUILDER DECLARATION%
subject to the Workers' Compensation provisions of the Labor' Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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 filea signed statement that he is licensed pursuant to
PERMIT
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
I hereby affirm that there is a construction lending agency for the performance of the
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the Any Section 7031.5 by 'any for
-Plan Chk. Dep.
alleged exemption. violation of applicant a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500)..
Plan Chk. Bal.'
O, I, as owner of the property, or my employees with wages as their sole compensation, will
Lender's Name
.� 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 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.) - ,
I certify that I have read this application and state that the above information is correct.
O I, 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.I.'
-such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
❑ I am exempt under Sec. B. & P.C. for this reason -
Validated by:
Driveway Enc.
Infrastructure
Date owner
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. , 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars (S100) 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.
TOTAL
REMARKS
AMOUNT
3!5.UU
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
_
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Street Setback from Center Line
I hereby affirm that there is a construction lending agency for the performance of the
—Side
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.,,
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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. - ' /
Validated by:
Signature of applicant) ' Date
Mailing Address i1 i.
Validation:
City, State, Zip 1
A5010
4 2 35,00 it
HARD COPY