0305-120 (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
752884 B Enc
01z/31 W
Date, Signature of Contractor ��✓,���
OWNER -BUILDER DECLARATION {'J
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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
Se�0ion 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 REPUSIC INDEMNIT' Policy No. 136'71601
(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: j Applicant
e/ V �Vi �.
Warning: Failu a to secure Workers\ mpensati6nn coverage is unlawful and
shall subject an, employer to criminal penalties and civil fines up to $100,000, ih
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.
<Z*-
nature (Owner/Agent) `'>-�'`J, ,. Date I I00
BUILDING PERMIT PERMIT"
03W -:I20 �.
DATE VALUATION ,Sa,95,175.50 LOT 47 TRACT ?9123.1
JOB SITE
ADDRESS 43 -MO PARKWAY ESPLANADE WEVYf
APN 609- -W3
OWNER
CONTRACTOR / DESIGNER / ENGINEER
POAIDIMOSA;HOIAES R, IIJC.
P0NDER0%3ATf01vl -R INC f
6671 OWMQ DRIVE
400 R FARRL+J2, DR 51'IM7 T3 10
PL,EABANTON CA
;PALM SPRn4GS CA 92262 �\
(703)1€i1-710 CW4 2348
USE OF PERMIT
MNO F FAM LY DWRTI 0
SFD- L0T 47 PLAN 3CX-L. PLAN DOES NOT INCLUDE BLOCK
WALLA POOL, SPA OR DIUVEWAY APPROACH, 75% RPIDUCTION TO PLAN
CHECK FEE DUE TO MULTIPLE ISSUANC'L? OF SAME PLAN TYPE
TRACT CONSTRUCTI(YO 3,053,00 3F
PORCH/PATIO 500.00 SIP
(9ARAOFMA€LPORT 381,00 OF
E:S'�'.QtWJIM (:0a7r OF COW1<'IdDa~`T1ton
185,775.50
P PJWT FEE SUAT 1!LARY
CONSTRUCTION FEE, 101-000-418-000 $940,50
PLAN CHECK FRE 101-000-439-318 $F94.30
MECRANICAL FEE 101X060-421-000 $90.50
FA,W,TIE1( ,FFE 101-000-420-000 $153.98
PLUMBING FEE 101.000.419.000 5174.30
S'I'IiUtdf: MOTION FEE - RE SID 101-000-7A I -000 $19.59
GRADIN FEE 101.00`0-423.000 S15100
DEVELOPER YMPA.i,T FEE $Z;!l0i,f30
D 4 S1' t T" C0NTML';CTTON AND PLAN CIMC.K
$4,000.86
1.1533 PRE -PAM FIBS
$0,00
JUN 0 6 lus
1003 _o rte,PKRM1111 mi DUE .NOW
Cory
NANO OUlNTA
E DEPT
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CtT
RECEIPT
DATE
BY /
DATE AL' INSPE A
Z - W , - %_._0
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
M CHANICAL APPROVALS
Set Backs
Underground Duc
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Coe
Grills
Fireplace T.O.
Fans & Controls 10
Party Wall Insulation
Condensate Lines I
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWA
—
L APPROVALS
Final
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 APPROVAL
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 APPROVA
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring 47 1�u
Fixtures
Main Service
Sub Panels i
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: