15248 (BLCK)Atyl
4Y-"70 & Vii. 4
f. 7-CIF,IL-45193 1C-19:i P.O. BOX1504 No. 15248
BluilnBuil n r'• ;; L- 78-495 CALLE TAMPICO
Address LA OUINTA, CALIFORNIA 92253 � / 4c, _17t;44
Owner
l`.c:;`t1T'; 1 r„
BUILDING: TYPE CONST. OCC. GRP.
Maifin --
Address 1 35 SOL:Fh "D" 3tr.rec"
City Zip Tel.
Szln.. P±_%rn nr tiny, CA 924Ct(909) 361-6007
Contractor
S-•_1tsr:.
Address
City Zip Tel.
State Lic. City
& Classif. T: 314473 Lic. # 212 0
Arch., Engr.,
Designer Frcl'Zk %Ui ZalOc3 & ASSO+.fdtt:F
I_M3 E�1s4- Chapmen Ave. IT%'714)532-687S
City Zip I State
g2666 Lic.#
LICENSED CONTRACTOR'S DECLARATION
ere by affirm that I am licensed under provisions of ChaPlor.9 (commencing with Section
of Division 3 of the Business and Professions Coda,en8 my license is in full force and
-SIGNATURE DATE
OWNER -BUILDER DECLARATION
1 1 her affirm that I am exempt from the Contractor's License Law for the fallowing
i! reason; {Sec. 7031A.Busiress and Professions Code: Any city or county which requires a
permll to consrru f, alter, improve. demolish, or repair any stmeture. prior to its issuance also
I requires the applicant for such parma to rife a signed statement that he !is ficensed pursuant to
[he previsions of Me Contractor's LJrvnse Law, Chapter 9 (commanc/rry with Section 7000) of
Givfsion 3 of rho Busvmoss and Profasskrns Coda, or that he Is exempt Merefmm, and the basis
for the Alleged exempfion. Any vx9at,iorr of Section 7031.5 by any aWkanf for a parmd
subjects the applicant la a ch.9 pana8y or nor more than five hundred dollars (S500),
❑ 1, as owner of the properly, or my employae8 with wages as their sole compensation, will
do the work, and the -structure is not intended or offered for sale. (Sec. 7044, Buisrress and
Professions Code, The Contractor's License Law does not apply to an owner of property who
builds or Ynprovos thereon and who does such work hemserf or through his own employees,
provided that such improvements are not inrended at offered for sate- fl, no wsvar, the bmntdmg
or improvement is sold wither one year of completion, the owner-buAder wNi have the burden
of proving that he did nor bidd at erporove for the purpose of sale.)
0 I, as owner of the operly, am exclusively Contracting with licensed contractors to con-
struct the project. 70��, Business and Prolesslons Code: The Contractor's License Law
does not apply [o owner of property who builds or improves thereon, and who contracts for
such projects wrap a contractor(s) jfcensed pursuant to the Contractor's License Law )
❑ 1 am exerppt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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 ND. Company _
F1 Copy is filed with the city. ❑ Certified copy is hereby furnished
t
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section tread not be completed if the pemn: is for one hundred dollars (SID01 vatuation
or less.)
I Certify that in the performance of the work for which this permit is issued, I shall not
employ arty person in any manner so as to become subject to the Workers' Compensation
Laws of California
❑ate ----------- Owner
NOTICE TO APPLICANT- it, after making INs Cerri6Cdfe 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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEYS FEES.
This is a building permit when properly tilled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 100 days,
[ 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 slate laws relating to building
construction, and hereby. authorize representatives of this city to enter the above.
mentioned property For inspection purposes.
A.P. Number
Legal Description •ixaCC 26153
Project Description 750 Z • f ' of 61 high garde_-n
privacy wall
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation a :. - Pm -it e 0 0
11
4-` T
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
198.00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Eric -
Infrastructure
TOTAL
i n +� n r•
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
Issued by: Date Permit
Validated
Signature of applicant Date
Mailing Address..
City, State, Zip
Validation: