15653 (PLBG)P.O. BOX 1504
Building 77 -ate Ave.. Montezuma 78-495 CALLE TAMPICO
AddressLA QUINTA, CALIFORNIA 92253
Owner
Michael Carta
Mailing ' Same
City lZip Tel.
Contractor,
Wner
Builder
Address.
Zip I Tel.:
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City (Zip I
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions 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.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he 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 is exempt therefrom, 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 rive hundred dollars ($500).
cJ
o,1,2s 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, Buisness 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 employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or Improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the "property, am exclusively contrmting with licensed contractors to con
-
a the project. (Sec. 7044, Business and.Professm ns Cod6: The Contractor's License Law
does not apply to an owner of property who builds or improve4T therei n, and who contracts for
such projects with a contractors) jicensed pu ant ro t Contrac&,r's Ll& se Law.)
❑ 1 am exempt under Sec. A B.J& P.C.rfor this . aso
WORKERS' COMPENSATION DECLARATION
(�ere/affirm thatI have a certificate of consent to self -insure, ora certificate of
Workers Compensation Insurance, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy Is filed with the city. -O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100) .valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any parson in any manner so as to become subject to the Workers' Compensation.
Laws of California
Date Owner
NOTICE TO APPLICANT: ff, after making this 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 deemed revoked.
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 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES. -
This is a building 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.
Signature of applicant Date
Mailing Address
City, State, Zip
N0. 15653
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number
,Legal Description
Project Description UFldergrJ:2n tom' 1i=b1na C n1y
r'13.alk of the ownO
Sq. Ft. No., No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep. '
t
Plan Chk. Bal.
Const.
Rear Setback from,Rea/r �rop. Line
Side Street Sett r' m "Center Line
Mech.
Electrical
Plumbing -
30.00
S.M.I.
by:
Grading
Validated by:
Driveway Enc.
Infrastructure
Validation:
TOTAL
3 0.00
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Geier Line
Rear Setback from,Rea/r �rop. Line
Side Street Sett r' m "Center Line
Side Setback rom P operty
�j�
FINAL DATE
Issued
y INSPECTOR
Date Permit
by:
Validated by:
Validation:
a: -
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW FEES
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
2ND FL. � SO. FT. p
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
OTHER APPJEOUIP.
DRINKING FOUNTAIN
SO. FT. ®
TEMP. POLE
URINAL
ESTIMATED CONSTRUCTION VALUATION $
GROUT
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SYSTEM
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP. ,
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
LRce�—
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SO.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
UND PLUMB[
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP. ,
FRAMING
FINAL INSP.
ROOFING
LRce�—
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIONATURESlINITIALS
GARDEN WALL FINAL