0305-121 (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
'752 B 141C OV3 )/.2(
,Date rl Signature of Contractor \-��% , !J, /� ,
\` (�Nj
OWNER -BUILDER DECLARATION v \t
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 WD9kMIT' 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 provlsi ns.
Date: 1 I/t— I r Applicant— 1AA A�'`'-'
Warning: Failure to secure Workers'�mpensation-couerage 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 inspection purposes. j
Signature (Owner/Agent) ��'\ i/� L -Date
BUILDING PERMIT PERMIT#
Wli0&_Y21
DATE VALUATION LOT TRACT
SX0q,244.70 46 ' 29323.1
JOB SITE
ADDRESS (:. _790 pAIUMAY iESPL.,&I` ADE V5 Erf
APN
649-980-023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PONDEROSA I.0)OS N, INC.
PONDF.T OSA 14019M 7.15TC
6671 OWRt1NU D}2iW
400 S. F�.J., DR. KH—VE B 103
PLEAS.ANfON CA
PALM SPR1N'C1S CA 92262
(703)187.710 (MLO 2346
USE OF PERMIT
KN'OLE FARr9 Y DWELLB 0
SFD - LOT 46 PLAN 1AXR PLAN i' OFS NOTINCLUDE BLOCK W.A1.iA
POOI1, SPA OR DIUVEWAY APPROACH, 75% REDUCTION TO PLAN CHECK
FEE DUE TO MUL`TIPUZ ISSUANCE OF SAME PLAN °i 5'PS
TRACT'' CONSTRUCTION 2,7n,00 SF
PORiC"r1M ATIO 32,3.00 SP
QARAGEfC.ARPORY 654,00 3F
E1,712VIA.'I ED COST OF COff1.'I92TJMON'
16;5,244.70
CONSTRUCTION FEF 101-000.418.000 $870.50
PLAN CHECK FELE 101-000.439-.318 $190.69
MECELANICAL FES: 101-000-421-000 $92,00
XLECTWCAI FEE 1. ()1-OiDCI-42®-G00 $142.06.
PLUMBING FLS 10.1-000-419-000 $167.26
S'i RONO.MO'TION FEE - RESID 101-000-241-000
QRADINO FRE 101-000-423-()00 VIM
DEVELOPER IMPACT FIZ $2,40"i.Ot3
MM -TOTAL COMM13 MON fiND�l�gi��.-6,W'
G+2�
CCB pCTK'p �+�;��
f`1
IMS PRF,-PAEDF --B
Q3r9`.
$0.00
�� `1'AL ffy11�:?Wt ]+ r S DUE IVOW
�,SS3!d.02
e
O v 4 V
-T
RECEIPT
DATE
BY
DA AL rj�
L_
r�
1/. . i. /',�,1
i
,_ 10 .11
(SPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
.6PERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
lei
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturnAir
✓
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Framing
i
421
.A.U.
Compressordly
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
steel POOLS -SPAS
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
lectric Final
Waste Lines
/
Heater Final
Water Piping
_
Plumbing Final
Plumbing', up 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 0.0
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors ,
Temp. Use of Power
Final Oq
Utility Notice (Perm)
COMMENTS:
r nereuy anirrn unuer penaty ur penury urar r am iwcnaau
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).
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.forwhich this permit is issued.
(") I have and will maintain workers' compensafion 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 . RERUBIC:INDEMNIT' Policy No. 13671601
(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,forwhich 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 complywith 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 thetcost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and att6rriey'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
whoserequest 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.
Signature (Owner/Agent) Date
L+vIL.vniW I L.1 11n1 I 030121
DATE VALUATION $165,244.70 LOT 46 TRACT 29323-1
JOB SITE
ADDRESS 43-790 PARKWAY ESPLANADE WEST
APN 609-380-023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PONDEROSA HOMES II, INC.
PONDEROSA HOMES II INC
6671 OWENS DRIVE
400 9. FAF.RE ? • DR SUITE B 103
PLEASANTON CA
PALM SPRINGS CA 92262
(703)187-710 CB1.# 2346
USE OF PERMIT
SINGLE FAMILY DWELUNG
SFD;- LOT. 46 : PLP,N:IAXR ,FLAN DOIP NOT INCLUDE BLOCK WALLS, . .
POOL,"SPA�OR DRIVEWAY APPROACH. 75% REDUCTION TO PLAN CHECK
FEE DUE TO MULTIPLE ISSUANCE OF SAFE PLAN TYPE
TRACT CONSTRUCTION 2,728,00 SF
PORCH/PATIO. 323.00 SF
GARAOEICARPORT 634.00 SF
ESTIMATED _COST OF CONSTRUCTION'.
165,244.70
PERMIT FEE SUMMARY
CONSTRUCTION FEE -101-000-418-000 E87Qi50
PLAN;CHECK FEE 101-000-439=318 $180:69 -
MECHANICAL _FEE 101'-000421-000 892; 00
ELECTRICAL FEE 101=000=420=000 SI4z"06
PLUMBING FEE 101-000-419-000 E167.25
STRONG MOTION. FEE • RESID 101-000-241-0.00 $16.52
GRADING, FEE. 101-000-423-000 813.00
DEVELOPER IMPACT FEE $3,405.00.
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$3,889.02
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$3,9.02
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR