26750 (SFD)y 'ti County of Riverside
e{,yl. Department of Building and Safety
4080 ter`ve St' n0 FI � 135 N. Alessandro Rd. Rm 203 880 N. Slate Street 227 North • 0" Street 46-209 oasis St. Rm. 310 150 N. Broadway
Ri,'rsldF/l.i1''s 50T Banning. CA 92220 Hemet. CA 92343 PUPS. CA 92370 Indio. CA 92201 Blythe. CA 92225
Ph: 787-6146 Ph: 849.7312 Ph: 658.4464 Ph* 657-3898 Ph: 342.8271 Ph. 922.2670
This permit becomes void if work not commenced within 180 days Iron date of issuance. OR, it work has beer suspended or abandoned for a period of 180 days
n
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be com-
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter9 (comment-
pleted if The permit is for one hundred (5100) or less. I certify that in the performance of the work for which this
i. permit istsued, I shall not employ any person in any manner so as to become subject to the Workers' Compensa-
ini� with Section 7000) of Division 3 al the Business and Professions Code, and my license is in lull force and effect.
tion Laws of California.
aDate
__ _Applicant
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
NOTICE TO APPLICANT: If, alter makingthis 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
following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to con-
deemed revoked.
struct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such
PING
permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
(Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is ex-
01 hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend. will
empt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a per-
mit subjects the applicant to a civil penalty of not more than five hunderd dollars 15500).):
be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework.
or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec 341.
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
Title 8. C.A.C.). .
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
0 A owner -builder. I will not employ anyone to do work which would require a permit from the Division of In -
Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or
dustrial Safely. as noted above. unless such person has a permit to do such work from the division.
through his own employees, provided that such improvements are not intended or offered for sale. If, however,
SB
the building or improvement is sold within one year of completion, the owner -builder will have the burden of prov-
[:)Division of Industrial Safety Permit No. _
ing that he did not build or improve for the purpose of sale.)
131, as owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec.
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the perfor-
mance of the work for which this permit is issued (Sec. 3097. Civ. C.).
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who
LICNC #
334436
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Con-
Lender's Name
tractor's License Law.)
Lender's Address
❑f am exempt under Sec. . B.B P.C. (Attach Certificate).
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance. or a certified copy thereof (Sec. 3800, Lab. C.).
❑Certified copy is hereby furnished.
❑Certified copy is filed with the County Building Inspection Department or County Department.
APPLICANT NAME (L, F, MO
HORN DAN
ADDRESS
BOX 16:38
CITY/COMMUNITY/STATE/ZIP
PALM DESERT CA 922100000
JOB SITE ADDRESS/SPACE
54100 AVE CARRANZA
CITY/COM MUNITYISTATEIZIP
LA QUINTA CA 922530000
BOK
PAG
PRC
C
TWIN
PING
SE
S
774
211
005
3
0000
00
TRACT LOT
000000 0024
MOD
011
SB
TRACT NAME
SCV LA 0 #26, FOLK -265
OWNER NAME (L,F,MI)
HORN, DAN
PHONE X
CONTRACTOR -FIRM NAME
DANAVON HORN
LICNC #
334436
ADDRESS
BOX 1638
CITY/COM MUN ITY/STATE/ZIP
PALM DESERT CA 922600000
PHONE#
714-560--10148
BLDG. INSPECTOR
FINAL DATE
ARC/ENG FIRM NAME
LICNC If
ADDRESS
1
CITY/COM M UNITYISTATEIZI P
PLAN #
PLANS EXAMINER
APPROVE DATE
USE OF PET
DWLGRMI
Ir ATGARAGE
BLZON
00F
Fit
FSB
020
SSB
010
SSB
005
RSB
010
1
OFC
INN)
I.
ZONE ORD #
LOT SZ
ENDSIDE
0050
0100
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cerfily I have read this application and state
that the information given is correct. I agree to comply with all slate laws and county ordinances relating to
building construction, and authorize a representative of the County of Riverside. Department of Building and Safety
to enter upon the property for which I have applied for this permit for the purpose of making inspections.
X
Signature of Applicant or Agent
Print Applicant/Agent Name
Date
APPL/PRMT # DATE-. 26705
A'; PS /2ti/8
1
TOTAL .
FEE
CA
CK
NC
COUNTER B.1.
CWNTER L.U.T.
APPLICATION FAR STRUCTURAL PIAN REVIEW
T H I S I S A N A P P L I C A T x O N n N L Y
You rust see the following.Departments of listed) for concurrence BEFORE
a Permit can be issued:
Description ----------------- Dept t o s d. ue�, �1 �
HOLD-- _ HEAT TF ,�
HOLY)-- r ROADA.
ASSESSOR - - - -- —