15854 (SOTB)P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address LA QUINTA, CALIFORNIA 92253
Owner E.G. WilliamS t7eV.
Corp.
Address 42-600 Caroline Court
City Zip Tel.
Palsy Desert, C1 92211 1(619)341-6880
Contractor
Avana Constructimi
Address
74055 Goleta
Paylm Desert, Ce zi�2260 re1340-0302
& Classif. 622301 1 Lic. # 1994
Arch., Engr.,
Designer
Address Tel.
City (Zip ( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
`hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
000) of Division 3 of thf BusineS§ and -Professions Code, and my license is lin full force and
SIGNATURE * �- -- - / `P DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Susiness 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 rile a signed statement that he is licensed pursuant to
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
subjects the applicant to a civil penalty of not more than Ove hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner or property who
builds or Improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
O I, as owner of the property, am exclusively contracting with licensed contractors to con-
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
such projects with a contractor(s) (icensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. B. & P.C. for this reason
Dale Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm; that I have a certificate of consent to self -insure, or, a„certificate of
Worker's gepensiiion Insurance, or a certtiffiied.copythereof. (Sec. -,3800, Latiorldode.)
Policy No..Company �^ wi'"✓'` .r'o ��..
b Copy is filed with the city, ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(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 the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: ff, 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.
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
ATTORNEY'S FEES.
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.
I 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 state laws relating to building.
construction, and hereby authorize representatives -of this. city to enter the above-.
mentioned property for inspection purposes.
Signature of applicant Date
City, State,
No-�5854
BUILDING: TYPE CONST.
A.P. Number
Legal Description
Project Description (7)
standards
OCC: GRP.
trash enclosureI3 per City
Sq. Ft.
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$4,775.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
72..00
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
72.00
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
Validated
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