PLBG (0110-264) + SFD (002026)54105 Avenida Madero
0110-264
002026
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
746159 S9 C4210C 01V2 at2
r
9 t
Date'` ' tfy 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).
( ) 1, 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
rSection 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 nTRY 1+`t;,¢ND Policy No. 119"10.%1-01
(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: 7/ 2 r f Applicant ' _
.. r,
Warnirig: 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 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) (' l ° E''✓'rl Date /t%' ,i `''ti j
BUILDING PERMIT PERMIT#
DATE r p VALUATION ,yLOT TRACT
JOB SITE
ADDRESS : '` r fwl:e ,3 iye i.A S+ }Jtw APN _
OWNER CONTRACTOR / DESIGNER / EN (NEER
Sa".,T,WR A 1'f--WNIT : r, C011TO 9010I/KR. S'fM.'id:i
yy54-105ry p 'Y p + D..)AV , 5E' C'f / e [ PALM
i y. pt AZ>ON i3.1 , Ii :VV /IO,922161
CgAfi: 2201
LA .. R.SY7 rA `A. 722 ?3 t` .0•' Y..21' . SJ.L 11 i` I 'wit! 921 6 h
(160)3465.27 +3 Coll# 342
USE OF PERMIT
1-1,131ABWO
il
dCA!'/R, L1.iii11710 COSTOF •.i.ri„+,f'QP9+IRE11M*.LOO
PIX IMMO MY, -- SIVNIRM 101 _000-419-000 %X00
D i,CA:7-TUNNT. Ct.Jklload.RU d..1OWPLS D P.6..A1-s' f'`.il.7.lCt.+cI us 13R -PAID PETO
i1`
TUXAL PERMU11,00 DUE NM
RECEIPT DATE J' t, 1 lel BY u DATE FINALED INSPECTOR
21f3W.W,
$ 30JA
$0.00
)DO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
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
Drywall - Int. Lath
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 ..
Sewer Connection 3 Ot .
Pool Cover
Encapsulation
Gas Piping
Gas Test
Applil3nces
Final
Final -7jQ57
Utility Notice (Gas)
ELECTRICAL APPROVALS
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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: t✓ S
Address: L- 10 t C- ,-1 e'
Account No. l Vta, ✓ , / {Z Lot(s)
Service Address -+ l j- ` , t x l:u ". , .,
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Q; anitation Capacity Charge i^
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ uncollected Account - Name
❑ Inspaction Fee - Tract -
ti
'
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
{] Customer Deposit
M nfhPr
Remarks
V079tt, AON^ 'xoQM
G.A. Code
TOTAL
0,r
1
❑copy to:
Cash Water Service
Check
Money'•Cashier
Order fie `` " ;r„” CVWD-438 (11189)
F.
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
JOB MORE ORDER
13474
FAX (760) 347-4978
ATE OF ORDER
JO
SERVICE CODE
PHONE
TE IICCCIIIAN
H PER
STARTING DAT
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOT L MAT RIALS
f J
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
BILL TO
TYPE OF WORK
`/
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
Q
❑ SEPTIC TANK
❑ GREASE TRAP
CITY
OE
❑ SEEPAGE PIT
JO NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION OF WORK:
CONDITION OF TANK BEFORE SERVICE
_ Good _ Trash & Garbage _ Excessive soap
_ Fair _ Overflowing _ Sand
Poor _ Blockage _ Repairs Needed
_ Very Poor _ Odor
_ Roots _ More frequent service needed
TOTAL PUMP
ISP FEE
TO L LAB
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOT L MAT RIALS
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
+
$
Signature
❑ No one home
❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
❑ Total billing to
be mailed after
completion
of work
Building
Address 54--105 AVerdlft M11519VID
Owner
Mailing
Address
City lZip ITel.
4
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
XIC1.1 '. .. I 1fJL I 3i g .GG
Contractor
Address
City Zip Tela
State Lic./ City
& Classif. 71(O Lic. # 1:2?4
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000).of Division 3 of the Business/and Professions Code, and my license is in full force and
effect. :r «
SIGNATURE' DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement,that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
.Division 3 of the Business and Professions Code, or lhat.he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or -through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not.apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
0 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.) -
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated,. d is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter] the above-
mentioned property for inspection purposes. f
s sSignature ofapplicant `- :G Date. r -
1.,_
Mailing Address
City, State, Zip
HARD COPY
No. 002026
BUILDING: TYPE CONST. Vii OCC. GRP. R 3
A.P. Number 774--192-016
Legal Description Int 5
Project Description
Sq. Ft. EM 1592
No. Dw.
Size 4f► Stories ' Units 1
New ❑ Add ❑ Alter O Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
318.52
Const.
379.00
Mech.
31,00
Electrical
76.17
Plumbing
89.i'0
S.M.I.
_ 5.71.
Grading
Driveway Enc.
20.00
Infrastructure
1,221.7.1
TOTAL
2.135, 06
.REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property,Line
FINAL DATE INSPECTOR
Issued by: Date 1-28-86 Permit
Validated by:
Validation: r
A 4 0 5 6 1 30-i 35 t,6 CK
7
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
2ND FL. SQ. FT. ®
POR. SQ. FT. @
GAR. SQ. FT. ®
CARP. SQ. FT.
WALL SQ. FT. ®
SQ, FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ®c
JBATH TUB
BOND BEAM
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR ® 3/ac
HOUSE SEWER
i FRAMING L' IGI
n FINAL INSP.
F (/
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP./EQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
,0 FINAL INSP. 6,6 Q
i FRAMING L' IGI
n FINAL INSP.
F (/
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
T INSULATION/SOUND L
t.
FINISH GRADING
FINAL INSPECTION
v
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
,4%f1ED
o
r. -o
H BERMUDA DUNES r
RANCHO MIRAGE
INDIAN WELLS H
PALM DESERT a
,P LA OUINTA
',p I N DIO
Desert Sands Unified School District
82-879 HIGHWAY 111 • INDIO, CALIFORNIA 92201-5678 • (619) 347-8631
January 29, 1986
City of La Quinta
Department of Community Development
78-105 Calle Estado
La Qui'nta, CA 92253
Re: 54105 Madero
Gentlemen:
The developer of the above referenced lot
has mitigated its impacts on our overcrowded schools by payment
of the amount of $628 per unit to be applied to the cost of
district educational facilities made necessary by such. new
development.
Sincerely,
SrL I-. VeAa
John D. Brooks
Assistant Superintendent
Business Services
JDB/crm
A.
r
Buena Engineers,inc.
1731-A WALTER STREET • VENTURA, CALIFORNIA 93003 e
March 5, 1986
Rick Johnson Construction
P.O. Box 2288
Indio, CA 92202
Pro j ect: 54-105 Ave. Medero
La Quinta, CA
Subject: Report of Field Densities
House Pad
RF -CE VED
MAR 17 1986
CITY OF LA QpUINTA
COMMUNITY DEVELOPMENT DEPT
0
PHONE (805) 642-6727
B -15862-P1
86-3-35
On February 21, 1986 a representative of our firm performed density tests
on the fill placed in the building area on the above referenced project.
Tests were performed at random locations in accordance with ASTM D
2922-81 and ASTM D'3017-78 Nuclear Density Test Procedure. Tests were
performed as per authorization of Rick Johnson Construction.
The estimated locations of the tests are presented on the attached plan
with their results being summarized on the attached test report sheet. A
total of two (2) density tests were performed. Test results indicate that
a minimum of ninety percent (90X) relative compaction has been obtained
within the,6reas-tested. The maximum density -optimum moisture were
determined 1n"the`latioratory in accordance with ASTM D 1557-78, Method
A or C.. Test results are as tallows:
Soil Description. USCS Maximum Density -Optimum Moisture
Dark brown silty
fine sand SM
VENTURA
(805) 642.6727
BAKERSFIELD SANTA BARBARA
(805) 327-5150 (805) 966.9912
109.1 pcf 14.9%
LANCASTER
(805) 948.7538
PALM SPRINGS SAN LUIS OBISPO
(619) 328.9131 (805) 544-6187
7
March 5, 1986 -2- 8-15862-P 1
86-3-35
1. The project is located on Ave. Medero in Le Quinte, CA.
2. Prior to our arrival at the site the grading of the building pad had been
comp] eted.
3. The purpose of testing was to observe compliance with City of La
Quanta requirements.
The test results summarized in this report present the moisture and
density only at the locations and depths tested on the specified dates. The
summarized field and laboratory tests were performed in accordance with
engineering principles generally accepted at this time and location. No
opinion is expressed as to the uniformity of the material, compaction, nor
adequacy of the material to perform its intended function. No guarantee or
warranty of the contractor's work is made or implied.
If there are any questions, please do not hesitate to contact this office.
Respectfully submitted,
BUENA ENGINEERS, INC_
t1' 6 - d - " 5-14 1
Norman G. Jackson, Sr.
NGJ/CSH/kls
F-7
Copies: 2 - Rick Johnson
2 - City of La Quinte
2-PSfi:le
1 - vTA file
Reviewed and approved
Craig S. Hil
Soil En '
A 0 CN 9
BUENA ENGINEERS, INC.
c
a
CE 24552 0
Exp, 12/31/89
s 9t o /V I L
F
CALIFOR P
BuenaEngineersin
ENGINEERING
REPORT OF RELATIVE COMPACTIONS
8-15862-P1
March 5 1986 Job No. 86-3-35
CONTRACTOR: DATE: + + CAReport No.
ADDRESS: JOB & UOCATION: La Quintan
TEST NO.
DATE
DESCRIPTION
% MOISTURE
DRY DENSITYRELATIVE
MAXIMUM
TESTED
IN PLACE
IN PLACE
COMPACTION
DENSITY
1
2-21-86
Per Plan FG
13.3
100.3
92
109.1
2
2-21-86
Per Plan FG
7.7
103.7
95
109.1
FG = Finish Grade
WE CERTIFY THAT THESE TESTS WERE PERFORMED IN CONFORMANCE WITH
COPIES
BUENA ENGINEERS, INC.
MIN
,4LIL 'Madz,<4
E x orovy
900 -SE
I
4#- 14kF OW E. &W9
"IRA ENGINEERS, INC.
um-3-ff-ft [FILE W.&ITft
BUENA ENGINEERS, INC.
1731-A Waiter Street
VENTURA, CALIFORNIA 93003
(805) 642-6727
TO
THE FOLLOWING WAS NOTED:
Al -5 j 'may
DATE J /
— -.,7 I w Z
JOB NO.
PROJECT
LOCATION
CONTRACTOR
OWNER
WEATHER
tf S ate'
TEMP.
O at AM
° at PM
PRESENT AT SITE
yf
a
.51-7
tf S ate'
rZ_-p . 7—,
/-
. o
yf
COPIES TO
upillmim
SIGNED
v