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Building Permit

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Please correct the field(s) marked in red below:

Date

 *

Permit No:

Use Zone

Occupancy

Construction Type

SQ Ft.

Project Info

Project Info

Applicant Name

Owner Info

Owner Info

Contractor Name

Contractor Info

Contractor Info

Contact Person

Contact Person

Project Name

Permit Type

Description of Work

Condition

CERTIFICATION APPEARING ON APPLICA TIONS

I have carefully examined the above completed *Application and Permit* and do

hereby certify that all information hereon is true afld correct , and I further certify and

agree , if a permit is issued , to comply with all City , County , and State laws

governing building construction , whether specified herein or not, and I hereby agree

to save, indemnify and keep harmless the City of Coachella against liabilities ,

judgments , costs and expenses which may in any way accrue against said City in

consequence of the granted of this permit .

CERTIFICATION APPEARING ON APPLICA TIONS

I have carefully examined the above completed *Application and Permit* and do

hereby certify that all information hereon is true and correct , and I further certify and

agree , if a permit is issued , to comply with all City , County , and State laws

governing building construction , whether specified herein or not, and I hereby agree

to save, indemnify and keep harmless the City of Coachella against liabilities ,

judgments , costs and expenses which may in any way accrue against said City in

consequence of the granted of this permit .

CERTIFICATION APPEARING ON APPLICA TIONS I have carefully examined the above completed *Application and Permit* and do hereby certify that all information hereon is true and correct , and I further certify and agree , if a permit is issued , to comply with all City , County , and State laws governing building construction , whether specified herein or not, and I hereby agree to save, indemnify and keep harmless the City of Coachella against liabilities , judgments , costs and expenses which may in any way accrue against said City in consequence of the granted of this permit .

I hereby affirm under penalty of perjury that I am licensed under

provision of Chapter 9 (commencing with Section 7000) of Division 3

of the Business and Professions Code, and my license is in full force

and effect.

Licensed Contractor's Declaration

Licensed Contractor's Declaration

I, hereby affirm under penalty of perjury that I am exempt from the

Contractor 's License Law for the following reason (Sec. 703.1.5,

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 or she 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 or she is exempt there from 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 ($500).):

Owner-Builder Declaration

Owner-Builder Declaration

Signature

Signature

I hereby affirm under penalty of perjury one of the following

declarations:

Worker's Compensation Declaration

Worker's Compensation Declaration

Signature

Signature

WARNING: Failure to secure workers' compensation coverage is

unlawful , and shall subject an employer to criminal penalties

and civil fines up to one hundred thousand dollars ($100,000), in

addition to the cost of compensation , damages as provide for in

Section 3706 of the Labor Code, Interest, and Attorney's fees.

I, hereby affirm under penalty of perjury that there is a

construction lending agency for the performance of the work for

which this permit is issued (Section 3097, Civ. C).

Construction Lending Agency

Construction Lending Agency

Certification

Certification

Attach Documents

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