15811 (BLCK)121
P.O. BOX 1504 iole8r
Building 78-495 CALLE TAMPICO
Address nru LA QUINTA, CALIFORNIA 92253
Owner
Or,.)
Mailing BUILDING: TYPE CONST.—OCC. GRP.
Address 41"")00 C,,?rolinc- Ct. A.P. Number
City Zip Tel.
Legal Description
Tract 1128019 Ma-o- ry -andf.-.Ti
Contractor Project Description
it
V"'allis Phzse-I Villas Lots 2 thru 19
Address
Block S
City Zip Tel.
State Lic. city
4S3919 1231
& Classif. Lic. Sq. FQ 9'6.W No. No. Dw.
Size Stories Units
Arch., Engr.,
Designer New 0 Add El Alter El Repair 0 Demolition El
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
7 of Division 3 of the Business and Professions Code, and my license is in full force and
effect.. W
SIGNATURE DATE
OWNER -BUILDER DECLARATION
Estimated Valuation
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.6,Business and Professions Code: Any city or county which requires a
permit to construct, after, 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 is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit Plan Chk. Dep.
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
0 1, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal.
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and 4 1 5 F5
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.)
0 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.I.
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading
0 1 am exempt under Sec.-B. & P.C. for this reason
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
q0 Copy is filed with the city. El Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
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 thV 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
DateOwnerNOTICE 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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND Side Street Setback from Center Line
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($1 D0,000), IN ADDITION TO THE COST OF COMPENSATION, Side Setback from Property Line
DAMAGES AS PROVIDED FOR IN SECTION 37D6 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES. INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE
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- 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 Validation:
City, State, Zip