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City
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PO. BOX 1504` APPLIMO LY
7OCALLS TAMPICO.,
LA QUIIINT VTA, CALIFORNIA.82253
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City Sp. Ft:. / No. No. Dw.
Lic. # a Size Stories Units
New' Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address lei. '
42-19s_ /r.(L.11c'�
City
Zip State
O Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and .
effect.
SIGNATURE - DATE
_
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following,
Estimated Valuation
reason: (Sec. 7031.5, Business and Professions Code: Any city or county which, requires.a
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permit to construct, alter, improve, demolish, or repairany structure, prior to its issuance also :
PERMIT A> — /3 90 AMOUNT
quires the applicant (or such permit to file a signed statement that he is licensed pursuant to'
provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
ision 3 0l the Business and Pro/essions Code, or that he is exempt therefrom, and the basis
Plan Chk. Dep. c l- Q
the alleged exemption. Any violation of Section.7031:5 by any applicant for a permit subjects
the applicant to a civil penalty o/not more than hve.hundred dollars ($500).
Plan Chk• Bal,
❑ 1, as ownei of the property, or.my employees with wages.as their sole compensation, will do
Const.
the work, and the structure is not intended or offered for sale. (Sec. 7044, Business and Profes-
sions Code: The Contractor's License. Law does not apply to an owner of propeny,who builds
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or improves thereon. and who: does such'work himself or through his own emplo eesprovided
that such improvements are not intended or offered for sale. If, however, the building or im-
provement is sold within one year o/.completion, the "owner -builder will have the burden of
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proving that he did not,build or improve for the purpose of sale).
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Plumbing,
❑ I, as owner of the property,{am exclusively contracting with licensed contractors to construct
the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does
not apply to an owner o/ property who builds or improves thereon, and who contracts for such
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projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading,-
❑ 1 am exempt under Sec. B. & P.C. for this reason
DrivewayEnc.� r•(s,,t -.;
Date Owner
Infrastructure
WORKER'S 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
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
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 the work for which this Permit is issued, I shall not
employ any person in any manner so as to become subject to 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 the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
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.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
Iration if work thereunder is suspended for 180 days. •
Icertity that I have read this application grid state thafthe aboveinformation is correct.
gree to comply withall'.city and countyordinances.and state laws relating to building
construction, and hereby authorize representatives of this city [o enter the above-mentioned
property for inspection purposes. '
Signature of applicant Date
Mailing Address
City, State, Zip
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
Issued by:
Validated by:
INSPECTOR
Date Permit
Validation:
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK= FINANCE