(BLCK)(49MAV
P.O. BOX 1504 APPLICATION ONLY
Building 78-105 CALLE ESTADO
Address QUINTA, CALIFORNIA 92253
_-6LA
Owner
BUILDING: TYPE CONST. OCC. GRP.
Mailing
Address
A.P. Number
City Zip Tel.
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x
m¢
Contract o tl �l
Legal Description
Project Des ription � � d X 2Qi11�'
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Adnn
dres
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City Zip
Tel.
X
State Llc. r�j �j�
& Classif. v`� f - 1
City �a
Lic. ff�Z 7�
Sq: Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Arch., Engr.,
• Designer
Address
Tel..
City
Zip
State,
Lic. #
LICENSED CONTRACTOR'S DECLARATION
Qrebyy affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
orDivision 3 of the. Business and Professions Coda, and my license is In fitlf force and
effect.
SIGNATURE DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the contractor's License Law for thefollowing
mason: (Sec. 7037.5;ausiness and Professions Code:, Any city or county which requiresa
perm!! fo construct, after. Improve, dsrrmoliah, or repair any sMloture, prior to Its Issuance also
reouirer the applicant for such perms to roe a signed staternimt mat he is Hcensed pwsuani to
the provisions of the Contractor's License Law, Chapter 9 (conrnenGng rmRh Ssetbn 7000) of
Division 3 of the Business and Professions Coda. or drat. he Is axerript therefrom, and the basis
for the alleged exemption. Any vioiatko of Section 7091.5 by 'any applicant Am a permit
subjects the applicant to a civil penalty of not more than Bre hundred'doilars (1500).
! _1 1, 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, Bulaness 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 amployees,
provided that such Improvements are not Intended or offered for safe. If, however, the building
or improvement is sole ,w1tlHri. one year of completion, the owner -builder wilt' have the: burden
of proving that hedidnot Guild or Improve for Mepurpose of sale.)
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. '
plan Chk. 681.
Const.
Mech.
Electrical
_
Plumbing
i i 1, as owner of the property,. am exclusively contracting with licensed, contractors to coo-
sirucl the project. (Sec. 7041, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who bunds or improves thereon; and who contracts for
S.M.I. '
such projects with a contractdr(s) HCansedpursuantto the Contractor's License Law.)
7 I am exempt under Sec. R. & P.C. for this reason
Grading
Driveway Enc.
Infrastructure
Date -Owner
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, (See. 3800, Labor Code.)
Policy No. Company
ri Copy 1whied with the city. ❑ Certified copy is hereby furnished.
TOTAL
REMARKS
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed X the permit is for one hundred dollars (1100) 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: IF, after .making this Certificate of Exemption you should become
ZONE: BY:
subject to. the workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback°from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
Ihereby affirm that there is a construction lending agency for the performance of the
work forwhich this permit is issued. (Sec. 3097; Civil Code.)
Side Setback from Property Line
Lender's Name
Lender's Address
This is abuilding 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.
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Signature of applicant Date
Mailing Address
Validation:
City, State, Zip
FINANCE
T4ht
78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA, 92253 - (619) 777-7000
FAX . (619) 777-7101
Date:
-,?/), A,
The City of La Quinta Dep . , t of Building and Safety has issued a retaining wad permit for
Address Apn %7 /.1 U L - Cbt/ , Lot & Blk �- 1
This permit is only for the pure se of constructing'a retaining wall at the above site. This permit
does not include filling the lot with dirt, grading, or commencing construction in any other way.
I am -aware that should any work other than for which this permit is issued, I can expect an
investigation fee added to mybuilding permit as allowed in the Uniform Building Code, Section
304 (e).
Builder Dat
Department of Building & Safety
Date
MAILING ADDRESS - P.O. BOX 1504 - LA QUINTA, CALIFORNIA 92253