0308-260 (CSCS)v
Malling
.Address
City'
8 Classif. nr-v n o /-- � Lic:11
P.O. BOX 1504
78-485 CALLS TAMPICO
tLAQUINTA, 0ALIFORNIA12253
L, P.
�7v' b'SMii
aff"M
Arc.:, tngr., S f E
Designer k IS ! v
Address Tel.
11741 f?') /YI / fir/ 7ZI- Qu (2 _ fr S I
x C.' pt"
LICENSED, CONTRACTOR'S DECLARATION
/,hereby affirmtthat I am Iicenaed.undar provlsloneol Chapter 9 (commenclRg with Section
7000) of Division 3 of the Business and; Prefesalona'Coda, and myiicense.1s Io.fu11'force rind
effect.
SIGNATURE DATE
OW N E114V ILDER; DECLARATION
1 hereby affirm. that I,am exempt from ttie Contractor's,Licensdi f aw for the following
`reason: (Sec: 7091:5 Buelnesa �arid Profesalona.'Code: My nay a county whkh requlles: a
peirixf to conatruct,`alter; .Improve demollah,. or.repd( my atnrcfure. pAor fo""ha' Issuance` elan
regiilres. the applkanl'Mi such permR, fo IiMa 8i9ned :sritement that he fa' llcenaed puisu'ant�td
Ne provlsiorrs of /lie Conlrecfork Ucarias Lair Chapter 8 (commenelnpwidt Seeflon 7000] of
GNision 9 of pie Buslnessantl.Rrelesabns lode: or that,Ae, /a exempt therefrom,, antl the+heals
for rhe alleged. exemption: Any v/olaflon of •Secf/on Z03f.5 Dy 'any, app9carlt for -a pemtlf
sub)ecte4he�applkantto;e,ebilpeileltyofnof more%fhenitive hundrod;ddkue (1500).
t'1,1,}as owner:ofjtheaproperty,'arti'excluslyely contracting with licensed contractors.to•oon-
struct the project. (Sec. 704-0, Business and Profsasions Code:_ The Contactors Ucerfse L8w-
does not ppply'fo an owner.�or.properry, who fxrnde. of improves 'M'ereon and 'who contraete. %dr.
such,projacfs with a,contracforfs) Ucenaed,'p'ursuant to`tfie.Contrector's'Llcense L'aw,j
17 1 am exempt under Sec:- S. & P:C. for this'reason
Date Owner,
WORKERS' C_OMPENSATION•DECLARATION
1 hereby affirm, that I"have a certificate of consent a.4
to self4risure, or,a,certlfic'of"
Worker's Compensation Insuradce;.or.a certified copy, thereof. (Ssc.-3800, Labor Co W:)
Policy No. Company
f7Xopy is.filedmith the city. O''Certified copy, is hereby,fumished.
CERTIFICATE'OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This secrlon need not be: congviated It the, permlf. is, for one hundred dosara '(Srf00) vduation
oalesa.j
I certify that, in, the performance.:of'!hq work far which this ipermit,isylssued, l shelllnot:
employ;any ppeerson In ,any. manner so as'tO, become subject to the worke(i,,Compenaatlon
Lawsiof Califor'nie.
Date .. Owner
NOTICE TO APPLICANT h, Mer maMng Mrs CerNHeate of ,Exemption you shorild baorne'.
c
suDjaot to the Workers Coriipensetloll prov181ons' of the Latii}r. Code, you must fa-dh4 h'
coniply;'irlth aucn;plo'yrslcjrla:or this pemiR Snal•be tlesmedYewked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that:'there is, a, construction lending agency fof'the,performance of the
work for which lMs�per^}It I I ued. (Sec, 309 Z; Civil Coda.)
Lender's Name /` /nii—Ok-
Lender's Address
This ;is a building perms w nprope'riy ed out; signed and validated,'an&is subject'to,
ezpirationre
,if work theunderiis su-spended1or180 days;.
1: certify, that 1 have read this application and :alate that theaboveinformation"is;correci:
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 an the above-
mentioned property forinspeclion purposes:
Signature of. aoolicant Date
Mailing Address
City, state, zip^ - r' , 1-�
..�" v
APPLICATION ONLY
.DING: TYPE'CONST. OCC. GRP.
Number
Number 72 3 , 3270 - ON — `t
Description
It Description
Ft. No.
Dw.
❑ Add ❑ Alter p Repair Demolition ❑'.
>v -
(got, E-J->e-/VZM//fC
45b -636 e-ISE-YUlMaJE
timated Valuat _ n /
PERMIT
Plan Chk: Dep:
Plan Chk. "Bal'.
Const:
Mech.
Electrical
Plumbing
s.M.l.,
Grading
Driveway Enc:
Infra
ZONE: BY:
Minimum Setback Distances:
Front Setback from: Center Line
Real 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:
Validations
WHITE =FINANCE YELLOW a ,APPLICANT' PINK-AUILDING; DNVISION