0307-232 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with'Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7528PA}� 0f3i"i 1/2t
Dat pe Y' ignature of Contractor f
OWNER -BUILDER DE AR }}TION
I hereby affirm under penalty of perjury that I am ex€mpt from the Contractor's
License Law for the following reason:
( ) I, 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, Business & Professionals Code).
( ) I, as owner -9f the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date' / Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent -to self -insure for workers'
compensation,,als provided for by Section 3700 of the Labor Code, for the
performance of(th' a work for which this permit is issued.
( ) I have andswill maintain workers' compensation insurance, as required by
Section 3700 of, -the Labor Code, for the performance of the work for which this
permit is issue !;vly workers' compensation insurance carrier & policy no. are:
Carrier R , f BIC WDEMNIT' Policy No. IS671601
(This section need not be completed if the permit valuation is for $100.00 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, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, Isha I .fort with51licant
mply with those provisions.
Date: >
Warning: Failure to secure Workr1VltPie
satio Co e'a-9e is unlawful and
shall subject an employer to criminand civil fines up to $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.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned pro15- fo inspection purposes.
Signature (Owner/Agent) �' " D � C r) o
BUILDING PERMIT PERMIT#
DATE VALUATIONLOT TRACT
165,2,14.70 44 25:3'$3.1 ,
JOB SITE py
ADDRESS lS J I �dlaLilWYn A�'sdltflllli'�
APN
�i1I-rll-t(
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PONDEROSA HOMES H INC
PONDEROSA HOMES 11 IWC
400 S. FA ' LL DR BUTTE B 103
400 S. k'iMMLL DR SUITE S 103
PP&M SPRINGS CA 92262
PALM SPRINGS CA 9226"
(703)187-710 CBIJ$ 2346
USE OF PERMIT
MWOI E k'AMIL T DWM124C3
St+'L1- LOT 44, PLAN 1=1t.. PERMIT DOES -NOT INCLUDE BLOCK
WALLAS, P0014 BRA 0R. DRIV9 WAY APPROACH. 16% RED UCTI0-9 TO
PLAN CHECK "M DUE TO MULTIPLY ISSUANCE OF MkME PLAN TYPE
TRACT CONSTRUCTION: 2,725.00 SF
PORC HIP.ATIO 423.00 SF
OARAGFJC".ARPORT 634ioo SF
X9M9AT= COs ' OF CONS711MUC!'nON
165a44.70
PlWAW NX 40 SU14M42YR
CONSTRUCTION F1s E 101.000-418-000 sm.59
PLAN CHUCK. FES 101-000-439-3118
MECHANIC.AL FEE 10'1.000.421.000 $92.00
ILZCTRIC AL fFZz 101-000-420-000
PLt9MB1140 FEE 101-000-419.000 7I8�.29
STRONO MOTIOW FF.E • R ESID 101-000-241-000
GIC&DIN0 IEEE 101 �0004V4.00 513,60
DEVELOPER IMPACT FEE
ff. UB -TOTAL C0Nffl'.R* CMON AND PIAN CHMC.
$3,889.02'...
LESS PRF -PAID FU3
$0.00:
AUG 0 5 2003
r'
RECEIPT
DATE
BY
DA QL INSPECTOR
Ll
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
A 1 001
Drywall - Int. Lath
Final
_
Final _
BLOCKWALL APPROVAL
POOL -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
r
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— L _ 3
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final00,
Utility Notice (Gas)
ELECTRICAL • APPROVALS
Temp. Power Pole _
Underground Conduit
Rough Wiring i
Low Voltage Wiring
Fixtures
Main Service _
Sub Panels
Exterior Receptacles
G.F.I. _
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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