0307-226 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed.under provisions of
Chapter 9 (comm'encin'g wiRSection 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
732884 1B MCS 09/31M
Date / Signature of Contractor �" -A A I n
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 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 of 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, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor.Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier R PIJBI v I14DLFei IT' Policy No. 11671601
(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, I shall forthwith comply with, those`pr�,,ovvlsio s.
Date: � 1/"'/ ,. Applicant ��� ���r
/r
Warning: allure to secure Workers Compensation cooerage is unlawful and
shall subject an employer to criminal penalties and 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 property for inspection purposes.
ign'ature (Owner/Agent` )` "R &,A_A 0"Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
S1'i2;�i3�,10 :SS A y323 -'i
JOB SITE
ADDRESS �w� ' ��I���1� �.b.it.rJ.A.�n,4v�.
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
POWDER 0SA HOWS TI TN'C
POND:F ZOSA HOME- 8 11 1K
400 9. FARRE .,I. DR. SUITR B 103
4x70 S. ]FFsR12EI.1.r DR ZW-rE B 103
PALM '"138 CA 92262
.PALM 9PRING 4 CA 92262
X03)187.710 C 51,9 23445
USE OF PERMIT
MWIG X FAhMY DWE.1 UNG
3DD - LO t^'33, PLr4AD 2AXL PERMIT GOES NOT i 4MUDE 81,OCK
WA.LL3„ POO., SPA OR DISE WAY APPROACH
TRACT CONSTRUC71014 2,036.00 SF
PORMPATIO 387.00 SI~
0ARAGEMARPORT 671.00 OF
,11MA= L'ogr OF CON6"M17MON
172,40.10
PEWAM IEEE SUPAMAc' N
CONSTRUCTION F9E 101.000.418-000 1995.00
PIAN CHECK FEE 101-000 4;>:9-318
WCHANICAL FEE 101.000-421.000 E 103.0ii
ELECTRICAL FEE 101-000-+420-0041
PLUMBINO FU 101-000.419.000 $163,50
STRONG MOTION FEE • D~`D_SID 101.000-241-000 $17.24
.
O12ADINO FEE 101.000-M-000 $13,00
DEVELOPER IMP.ACI F&5i $2,405.00
SUBTOTAL CONMUC IONAN? PLAN CHECK
5
S4,496,85
1M PRF,-PAIT) FSS
$0.00
=�--" P 1b9:I:t' 1iMrs DUB' NOW
i t
,496.85
n5 2UPC, 03
RECEIPT
DATE
r—
BY
!
OSE FIN ED
J
JrPE, `y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
. BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts ,
Forms & Footings
—
Ducts
Slab Grade
'jr,
I Return Air Col -
Steel
Combustion Air
Roof Deck
O.K. to Wrap 7
Exhaust Fans
F.A.U. vv
Framing
Compressor10
.Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
20 T -
Drywall - Int. Lath
Final -
Final —4
*•BLOCKWALL A PROVAL
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMING PPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
/
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-o 5 7
Encapsulation
Gas Piping
Gas Test
Appliances
40
Final
Final
Utility Notice (Gas)
ELECTRICAL APP VAL
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors _
Temp. Use of Power
Final _
Utility Notice (Perm)
COMMENTS:
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
752884 B HIC 08/31/2(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 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 of, the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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 rhiiintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section -3700, of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers.' compensation insurance,; as required by
Section 3700 of the Labor Code, for &,performance of the work fWwhich this
permit is issued. My workers' compensation insurance, carrier & policy no.. are:
Carrier REPUBIC INDEMNIT' Policy No. 15671601
(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, i shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and.
shall subject an employer to criminal penalties and 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-resultof 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 property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
0307-226
DATE VALUATION $172,402.10 LOT 33 TRACT 29323.1
JOB SITE
ADDRESS 43-725 PARKWAY ESPLANADE WEST
APN 609-380-023
OWNER
CONTRACTOR/DESIGNER/EN INEER
PONDEROSAHOIAES II INC
PONDEROSAHOMIES 11INC
400 S. FARRE •T • DR S= B 103
400 S. FARRE L DR SUTTE B 103
PALMI SPRINGS CA 92262.
PALMI SPRINGS CA 92262
(703)187-710 CBL# 2346
USE OF PERMIT
SINGLE. FAMMY DWELUNG
SFD - LOT 33, PLAN 2AXL. PERMIT DOES NOT INCLUDE BLOCK
WALLS, P004 SPA OR DRIVE WAY APPROACH
TRACT CONSTRUCTION 2,838:00 SF
PORCH/PATIO _ 387.00 SF
`OARAOEICAR.PORT 671.00 SF
ESTIlVIATED .COST OF CONSTRUCTION
172,402.10
PERIWr FEE SUMMARY
CONSTRUCTION FEE 101:-000.418.000 8895.00
PLAN`CHECK FEE 101-000;439-318 $744.86
MECHANICAL FEE 101-000-421-000 S105.10
ELECTRICAL FEE 101-000-420-000' $146.25
PLUMBING FEE 101-000.419.-.000 $168.50
STRONO MOTION FEE - RESID 101-000-241-000 $17.24
GRADING FEE 101.000.423.000 $15.00
DEVELOPER, IMPACT FEE $2,405.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,496.85
LESS PRE -PAID FEES
$0.00
TOTAL PERMTT FEES DUE NOW
$4,496.85
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR