9801-152 (SFD)4
P.O. BOX 1504
Building % Vi '% 78-495 CALLS TAMPICO
Address • ! Y 56 V �4 I r / 003 C LA QUINTA, CALIFORNIA 92253
UW ner r
Mailing Address ��•7D ro 1( /ao�C1r � .20
Ci Tel.
„A„tilzi�a 7os 71Y
Contractor
1 T70 r�o4,4¢146.0 l,-,1„< V.,;ot
CA . Zipr T I
?&,J.. 4,, ,, 7o 60 76,34
State Lic. City
8 Classif.�Q �j �� S6 Lic. # Alys,
Arch., Engr., � I e *�
Designer �.(� /I/n o2
Address Tel.
Cityf t r lip y O State
J � Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
I= of Division 3 of the Business and Professions Code, and my Ilcense is in full force and
I ffect.
"14"FIE DAB
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason; fSec. 7031-5.8usfnoss and. ProfeSsfons Cade: Any city or co✓lnly which requirar. a
permit to conslruct, affer, Improve. denraNsh, or rapelr any stfuohu , prior to its issuance also
rogm0 a rho Opp"( for such parmff to (Ne a signed sfalemonl that he is Ilconead pursuant to
the provisions of the contraelar's License f.a w, Cnapier 9 (commencing =J 5 fibn 70001 of
Owsiun 3 of the Busimss and. Professions Code, or that he is exempt therarrom, and the basil
for the afted exemption. Any violation of Section 703f.5 by any ��ppscan� fora perrn+f
subjects the appkcmf 10 a OW penally of ncr more than five hundred dotlars ($ 00).
I ' I, as owner DI the property, or my employees with wages as their so{e compensation, will
do the work, and the structure is apt intended or offered for sale fSac, 7044. 9idwiess and
Professions Code: The Conhacfor's. Ocanso Law does not apply to an Dwnar of properly wnd
buadx or mps vex the eon and wtro does such work himsed or itrraugh his own employees,
provood that such fmprorements are not intended ar offered for sale. if, howevar, the b4Ading
or fmprovament Is soil withal one year of completion. the ownar•buWar w4f nave the bd(don
of era Plop Thar he did not build or Irrrprove far the purpose of safe.)
f l 1, as owner of the property, am exclusively contracting with licensed contractors to con-
5lrucl the oeolect. (Sec. 7044, Business and Profestions Cade The Conlracroe'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)
7 1 am exempt under Sec. B. 8 P.C. for this reason —
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I hav ! a certificate of consent fo self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereol. (Sec. 3800, Labor Code.)
Policy No. Company
f1 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
fTtk5 seeflon need not be completed if the permit is for one hundred dollars (! 100) valuation
or tass:J
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 became subject to the Workers' Compensation
Laws of Cetl prom.
Date Owner
NOTICE TO APPLICANT: If, after make iy iens Certificate of Exampdun you should became
subject to the Workers' CPmpensa0on provisimns of the Labor Code. you must forthwith
comply with such provisions or flifs perm)! 54ia4 be deemed rarnked,
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 I
Lender's Name _
Lender's Address —
This is a building penult when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
certify that I have read this application and stale that the above informatlan is correel.
I agree to comply with all city and county ordinances and stale laws relating to building
construolion, and hereby authorize representatives -of this city to enter the above,
mentioned property for tnepeclion purposes.
Signature of atiplican! Date
Mailing Address _
City, State, Zip
*Ij, - /5-�
APPLICATION ONLY
JILDING: TYPE'CONST. ►►+/ pCC,GRP. /Z
P. Number m 13 — / 30 � Q} �y' o
gal Description , 6-/ 5 4/ r or 6 y ..�
Project Description ii
Z,, L/r /-,& Qw," L -C r44-
5g. Ft. a ��
Size
No.
Stories
No. Dw. ,
Units
New 2f Add ❑
Alter ❑
Repair ❑ Demolition ❑
Id 3
IV6 C
v C sf 9V L)
�_•C.�{
Estimate"aluation
rho
47'C'JV
PERMIT
--- AMOUNT
Plan Chk. Drip-
Plan Chk. Bal-
Const.
Mech.
Electrical
Plumbing
S.M.I.
l
Grading
-'
Driveway Enc.
a
Infrastructure
f-+
•.
TOTAL
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 by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION