0305-122 (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
152884 B MICy 08/3,1/2(
Date JI - 2 Signature of Contractor'
(
OWNER -BUILDER DECLAR�ION
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 REPUBIC! INDEWIT' Policy No. 1.9671601
.(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: � I - I - � Applicant` = , — --1 -A % A •lam°-
,.- 1 � � �
'Warning: Failure to secure Workers' C~mpensation cov"e�age is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application, is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result, of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days .will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/ S,ignature (Owner/Agent)` ` Date ".• V�
BUILDING PERMIT PERMIT#
030&122
DATE VALUATION.LOT. TRACT
M,
S2'72�C32,1CI 45 29323.1
JOB SITE APN
ADDRESS 43-74(O PA.RMAY .cPWLA14A.DE WEA CW -380-023
OWNER CONTRACTOR / DESIGNER / EN (NEER
PONDEROSA ROiMES El .DTC. PONDER03 h HOIvT0.11 INC .
66111 OWENS DRJVE 400 9. i?pilt-4IIX , DR SCTITE B 103
Pt"ZANTON CA PALM. t.-MMST&S CA 92262 -
,703)187.7.10 CMA. 2346
USE OF PERMIT
ISINGUE FAMILY TyWF.LUNO �.
3190 - LOT 45 PLAID 2BXL PLAN DOES NOT 114CLUDF R1,OCK: WA14.3y
P0014 sPA OR DRIVEWAY,APPROACH. 75%RP.I3UCTION 1'0 PLMI CHFAX
FEE DY. K TO MULTIPLE ISSUANCE OF S"K. PLAN TYPE
x
TRACT CONSTRUCTION 2,53$,00 9i
PtORCHIPA'PIO f 33'7.00 SF
0A18140L4 ARPORT 671.00 3F
E91MWX17M COST OF CONSTRUCrIOW
PEIUVzr ;1+"M &WWW"Y
BY
CONSTRUCTION FER
101.000.418-000
$999.00
PLA14 CHECK F9117,
101-000-439-318
9186.22
MECHANICAL FZE
101-000-421-000
6105,00
F%EC`TR.IC:AIJ F?,L
101
$146.25
PLUMBINO FEE
101-0000.419-000
$169,50
STR.ONQMOTION PRET - RLSID
101-000-241-000
$17,24
ORADWO FELE
101-000.423-000
�15.0b
DIMPILOPER IMPACT YBE
TOM. CO2aS7"iT.TJ'C'i ON AND MAN CHECK.
USS :PR;-PAYll FFM
UN o 6
>� ?x03
RECEIPT I DATE
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BY
DATE' IN
SPECTO
[
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Q'ZE
Steel
Combustion Air
Roof Deck.
O
`
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
Drywall - Int. Lath
An
04
Final -
Final
BLOCKWALL APPROVALS
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
PLUMBING APPROVALS
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
Encapsulation
Gas Piping
Gas Test
/
-
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures Of
Main Service
Sub Panels
Exterior Receptacles _41 If
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) _Y'24fkV F -E -Z
COMMENTS: