No Permit Number (BLCK)P
P.O. BOX 1504 APPLICATION ONLY
78-105 CALLE ESTADO
Address - ` A V ' LA QUINTA, CALIFORNIA 92253
Ow n er
LC.., �c
(� BUILDING: TYPE CONST. OCC. GRP.
Mailing
Address C(5 -?� I SLI/o/�/�.vC �T Sj - A.P. Number z
City Zip Tel.
o ( cf 5 7 Legal Description Aa f L (o
Contractor Project Description
Address
City Zip Tel.
State Lic.
City
& Classif.
Lic. #
Sq. Ft.
Size / 3 S Stories Units
Arch., Engr.,
Designer
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address
Tel.
` I_ w A L-
h
City
Zip
StateQ
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencingwith Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE D1 E
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, 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
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 five hundred dollars (5500),
C; 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 of 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
or improvement 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.)
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
I I, asowner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's Ljcensa Law
does not apply to an owner of property who builds or improves thereon, and who centrads for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
I l I am exempt under Sec. B. & P.C. for this reason
S. M.1,
Grading
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
Copy is filed with the city, E! Certified copy is hereby furnished.
TOTAL
REMARKS
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 thip work for which this permit is issued, I shall not
employ anyparson in any manner so as to become subject to the Workers' Compensation
Laws of Calilorrnla
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_
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
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.)
Side Setback from Property Line
Lender's Name
FINAL DATE INSPECTOR
Issued by: Date Permit
-
Validated by:
..
Lender's Address -
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 aerlify that I have read this application and state that the above information is correct.
I agree to comply with all city anri county ordinances and *tate laws totaling to building
constructian. and hereby authorize representatives sof this cfty to enter the above-
rnentionad prgperty for inspection purposes.
Signature of applicant _ Date
Mailing Address_
Validatian
City, State, Zip
APPLICANT