PP 1996-5782
4
P.O. BOX 1504
78.105 CALLE ESTADO ..
4 1 , "6A 1 1 0A 40"A )jA ;,T14LA OUINTA, CALIFORNIA 92253
APPLICATION ONLY
11LDING: TYPE CONST. _ OCC, GRP.
P. Number 77 3 - OZO -033
:gal Description Al w YY S BC'rjon7 i s , T6 S., R 6 E
oject Description G OLF 8^4 BARRIFR Pnl YE57rd
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State Lic. City
8 Classif. S 76 39 2 Lic. If
rm•., cnyr., - .
Designer ' V
Co5rA MESA I " 92621 I�ic N 1823
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� 4 d LICENSED CONTRACTOR'S DECLARATION
I hefeC / / nbrn that I am licensed under provisions of Chapter 9 (eommsnelnp with Section
70DO) of Division 3 01 the Business and Profession$ Code, and my license is in full force and
effect
SIGNATUFE' DATE
OWNE &BUILDER DECLARATION -
1 hereby affirm that I am exOMPT from the Contractoes License Law for the following
reason (Sec. 1031.5.Suaness ihd Processions Code: My CRY w coWrfY wroth yoWes a
pe/md M constNet, fear improve, dwMNae, or repYr any structure. prior to nee iNUalee Yao
'puns: the appacam (or such pawns ro No a sipnod storunenf that he b scanned purSuad to
me omywans or me Contractor's Lcense law. Chapter 9 (Commencng, earn Section 1000) d
Division 3 or he Business an" Prolsssgns Code, or that he b eaernsrl m than, orb new boors
cur the asageo saemption. Any wole0ch of S.I. )031.5 soy any appWanf W a jMrme
..peers the appripMt to a crw penalty or nor more man ova hop's doKbs ($500).
1, as owner of the property, or my employees with wages As their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Soc. 1011, Suwles$ and
Probsarons Cods, me Contractor ns
's I.rcae Law does nd appiv 10 an owner a property Who
-
WIM or mpmves in. and Wto does such work hahswt a mrown his own arrlpnyaes.
provged rnat such improvements we nor ",1Mded or offered for also. ff. how ,xv. red OWd%p
or rmprovampr rs odd with", one year of completion, me owner -p'W!r whe.Nye the burden'
or proylnq (Nt he Did nal DdM w ",prow for the pWpoae w asb.)
`.(I. as owner of the propMy, am exclusively contracting with licensed contractors to coo-
stNCt the proiecL (Sac. )case. Business and Pr lossrons Code: The Conlnxtors License Law
does not why to an owner of property wed paps or klprOWE Hanson, and wed counters ror
Such projects won a conlraclor(s) "nsec purswnt ro the conPacror's L6cMSe Vw.l
I am exempt under Sec. B. 8 P.C. for this reason
Date Z Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to wit - insurer or a certificate of
Workers Compensation insurance, or a certified copy thereof. (Sec. 3800.1 r Code.)
Policy No. Company
COPY IS filed with the cilY. Cartilied COPY is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS COMPENSATION INSURANCE
(This ssolkin hoed - pt be compares n the oame, is ror che nuMp ddrs ($700) vWalwn
or ris.)
I certify that in the performance of the work for which this permit is issued, I shut not
employ any person in any manner so to "come subject to the Workers' Compensation
Laws of a1 1 ia. 7 � • // • 21 ovi �"
Date Owner 1 4 r'Iyar.� O(A OF Aill"'IY
NOTICE TO APPL m M w
ICANT: ff, aeer akog 'his C icate or Explpn Ye should become
supecr to me Workers' Comp hoe"on prows"I's of me Labor Cade, You must '",loon
comply wan such W.-.S or Ines oemn Shit/ be Mimi nwka0.
AJ /Q CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of.the
work for which this permit is issued. (Sec. 3091, Ciye Cope)
Lender's Name
Lender a Address
This is a building Permit when properly filled pt; signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify Iht I have read this application and stale that the above information Is correct.
1 agree to comply with all city and county ordinances and State laws relating to Wilding
construction, and hereby authorize representatives of this city to enter the abws
mentioned propMy lorinspeclion purposes.
Signature of applicant Date
Mailing Address
City, State. Zip -
pa
Ft. Sap a ' - No. - No. DIN.
El X 20. Stories - Units
NewJK Add ❑ - Alter Repair ❑ Demolition
PERMIT
Plan Chit. Dep.
Plan Chit. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
infrastructure
/3, 759.
AMOUNT
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 - Permit
Validated by:
Validation: