RER (10-0532)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation: .
Applicant:
6WN&k
10-00000532
51864 AVENIDA MENDOZA
773-182-005-20 -000000-
REMODEL - RESIDENTIAL
COVE RESIDENTIAL
2000
Architect or Engineer:
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
MICHAEL & KATHERINE
53333 AVENIDA DIAZ
LA QUINTA, CA 92253
(760)564-0639
Contractor:
Owner
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
AN -,) - n
v �O�tJ
o�iyTq
QT•
Date: 6/25/10
-------------------------------------------------------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION - WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. 1 _ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: License No.: - for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
Date: Contractor:
--� OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
following reason (Sec, 7031 .5, Business and Professions Code: Any city or county that requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he or she 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).:
(_ 1 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 and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
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 or she did not build or
improve for the purpose of sale.).
(_) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant to the Contractors' State License Law.).
(_ 1 I am exempt under Sec. , B.&P.C. for this
reason
Date: 191W/0 er. /1Qt
CONSTRUCTION LENDQ2,kGENCY
I hereby affirm under penalty of. perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.I.
Lender's Name:
Lender's Address:
LQPERMIT
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 and policy number are: -
Carrier Policy Number
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
� /�p/J1 /700 of the Labor C de, I shall fo hwi om y with those provisions.
Date:"' (� PPliya
WARNING: FAILURE TO SECURE WORKERS' COMPENSATIO VERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the
conditions and restrictions set forth on this 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 application,
the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City
-of La Quinta, its officers, agents and employees for any act or omission related to the work being
performed under or following issuance of this permit.
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 county ordinances and state laws relating to building construction, and hereby authorize representatives
of thi
s unllenter upon the above-mentioned prope for inspectio
Date Signature (Applicant or A 1:
Application Number . . . . . 10-00000532
----=- Structure Information EXISTING SFD 786SF
-----
Other struct info . .
. . . CODE EDITION
2007/08 ENERGY
----------------------------------------------------------------------------
# BEDROOMS
.00
Permit
BUILDING PERMIT
Additional desc
SCREENING
Permit Fee . . . .
45.00 Plan Check Fee
29.25
Issue Date . .
Valuation . . .
. 2000
Expiration Date
12/22/10
Qty Unit Charge
Per
Extension
BASE FEE
15.00
15.00 2.0000
------------------------------------------
HND BLDG 501-2,000
----------------------------------
30.00..
Permit
MECHANICAL'
Additional desc
3 TON PKG UNIT
Permit Fee . . . .
33.00 Plan Check Fee
8.25
Issue Date
Valuation . . .
. 0
Expiration Date
12/22/10
Qty Unit Charge
Per
Extension
BASE -FEE
15.00
1.00 9.0000
EA MECH FURNACE <=100K
9.00
1.00 9.0000
EA MECH B/C <=3HP/100K BTU
9.00
--------------------------------------------------------------------------=-
Special Notes and Comments
REPLACE ROOF TOP HVAC
UNIT W/ 3 TON, 14
SEER, 12 EER PKG UNIT
& SCREENING PER
PLANNING DEPT. 2007 CODES
/ 2008 ENERGY.
----------------------------------------------------------------------------
Other Fees . . . . .
. . . . BLDG STDS ADMIN (SB1473)
1.00
ENERGY REVIEW FEE
2.93
STRONG MOTION (SMI) - RES
.50
Fee summary Charged
Paid Credited
Due
----------------- ------
Permit Fee Total
--- ---------- ---------- ----------
78.00 .00 .00
78.00
Plan Check Total
37.50 .00 .00
37.50
Other Fee Total
4.43 .00 .00
4.43
Grand Total
119.93 .00 .00
119.93
LQPERI%IIT
Bin #
City of La Quinta
Building 8z Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
i O
1
Pro'ectAddress:
1 J / ` eti ,// / /►�OZ
Owner's Name:
A. P. Number:
Address: s% -33
Legal Description:
City, ST, Zip: ZAR"I
Contractor: LJ v1,,
� /1�a� 'pv►/L �(L
Telephone:
N:,: r:<;;•A>:;<< ;::::<r::; ::
Address:
Project Description: l/cE 9. G 6,(Al> ? d.W
City, ST, Zip:
APDr , ' HY cSGe ESN/N
Telephone:..:::::;.;::>:>:>:<';;a:.
«:r%<;
State Lic. # :
City Lic. #;
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:#'.`€A<'<'>'.':
':'::
:;::»><;;::.;;:::::::•:::
i:<^y
Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: M 1K,9 oi/fA&F,4
Sq. Ft.: '79
1 # Stories:
J # Units:
Telephone # of Contact Person: " 7(o _ 5-7 8 _ -vD'7 S
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
7
om
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2•" Review, ready for correction issue
Electrical
Subcontactor List
Called Contact Person
6
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''" Review, ready for correctionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date or permit issue
School Fees
Total Permit Fees
1p, `0, % I
J
wo® ,
P.O. BOX 1504
LA QUINTA; CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY O'WNER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits'
1AWfd. A NT'1 No.. - E T(1 >P . QDIWRTY n��R
Dear Property Owner.
An. application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at
We are .providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue s building permit until you -hove read, iditialod your understanding of each prevision,
signed, and returned this form to us at *our official address indicated. An agent of the owner cannot execute thin notice
unless you, the property owner, obtain the prior approval of the permitting authority.
I: fR"EMONS. head and initial each. statement below to signify you andtrstand or verify tris information.
1. I understand a frequent practice 'of unlicensed persons is to have the property owner obtain an "Owner -Builder"
ding permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as
an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property -
2. I understand building permits are not required to be signed by property owners unless they are responsible for the
onstruction and are not hiring a licensed Contractor to assume this responsibility.
k3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her time instead of my
own.
k4,1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
n1
6. I understand if I am considered an "employer" under state and federal taw, I must register with the state and federal
government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk
7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residentia
structures cannot legally build them with the .intent to offer them for sale, unless all work is performed by license(
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performer
under contract with a licensed general building Contractor.
A
A�8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
financial or personal. u}juries sustainedby any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-
800-321-CSLB (2752) or www.cstb.ca.gov for more information about licensed contractors.
kL0. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
pY legally and financially responsible for proposed construction activity at the following address:
agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
*---,.cab
le liws and requirements that govern Owner -Builders as well as employers.
2.1 agree to notify the issuer of this form immediately of any additions, deletions, or changea to any of the information I
aveprovided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a license,. bre Contractors' State License Board may be unable to assist you with any financial loss
you may sustain as a result of a complaint_ Your only remedy against unlicensed Contractors may be in -civil court. It is also
important for you to understand thatif an ualicensed Contractor or employee of that individual or firm is injured while wod dng
on your property,' You may be held liable for damages. If you obtain a permit as Owner -Builder. and wish to hire Contractors,
You will be responsible for veri ging whether or not those Contractors are property licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for isstt€ug t ..p mit, Note: A copy, of the property owner's d ve rIs, ' cs (erne notar�Oasban4 or
other verification acceptable to tire' agency is required to be presented when the permit is insued to verify the property
owner's signature.
Signature of party o Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the exewtion of which I understand is my personal responsibility, I hereby authorize
the fallowing persons) to act as my ageat(s) to apply for, sign, and file the documents necessary to obtain an Owncr-Buildet
Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required Co be presented when the permit is issued to verify/the property owner's signature..
Property Owner's Signa Date:
.• M
AMU—=
Prescriptive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations (Page 4 of 5)
Pro'cst N ne: Climate Zone # # of Stories
I- A` q AvEN l PA 6 -Al U z A 5
HVAC SYSTEMS - HEATING
List water heaters and boilers for both domestic hot water (DHW) heaters and hydropic space heating. Individual dwelling DHW healers must be
gas or propane fired, and may not exceed 50 gallons. Hot water pipe insulation from the DHW heater to the kitchen(s) and on all underground
Minimum
Duct or Piping
Configuration
Heating Equipment
Efficiency
Distribution Insulation
Thermostat
(Central, Split,
Type and Capacity 1•2.'
AFUE or HSPF
Type and Location R -Value
Type
Space, Package or Hydronic)
CEVAI-t X
System
+(,T5
Thermal Efficiency
I�r9C6C� 6+s
1. Indicate Heating Type (Central Furnace, Wall Furnace, Heat pump, Boiler, Electric Resistance, etc)
2. Electric resistance heating is allowed only in Component Package C, or except where electric heating is supplemental (i.e., if total capacity
< 2 KW or 7,000 Btu/hr electric heating is controlled by a time -limiting device not exceeding 30 minutes). See ,¢151(6)3 exception.
3. Refer to the HERS Verification section on Page 4 of the CF -IR -ALT Form for additional requirements and check applicable boxes.
4. Indicate Type or Location (Ducts, Hydronic in Floor, Radiators, etc.)
HVAC SYSTEMS - COOLING
Minimum
2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of §150(n). The Prescriptive requirements do
Efficiency Duct or Piping Configuration
Cooling Equipment
(SEER/EERor Distribution Insulation Thermostat (Central, Split,
Type and Capacity 1,2
COP) Type and Location' R -Value Tye Space, Package or Hydronic)
IC
1. Indicate Cooling "Type (A/C, Heat pump, Evap. Cooling, etc)
2. Refer to the HERS Verification section on Page 4 of the CF -JR -AL T Form for additional requirements crud check applicable boxes.
3. Indicate Tye or Location (Ducts, Hydronic in Floor, Radiators, etc.)
WATER HEATING
List water heaters and boilers for both domestic hot water (DHW) heaters and hydropic space heating. Individual dwelling DHW healers must be
gas or propane fired, and may not exceed 50 gallons. Hot water pipe insulation from the DHW heater to the kitchen(s) and on all underground
hot water pipes is required in all com onent packages in all climate zones.
External Tank
Water Heater Type/Fuel
Distribution Type
Number In
Tank
Energy Factor or
Insulation
Type'
(Standard, Recirculating)2
System
Capacity (gal)
Thermal Efficiency
R -Value'
1. Indicate Type (Storage Gas, Heat Pump, Instantaneous, etc.)
2. Recirculating systems serving multiple dwelling units shall meet the recirculation requirements of §150(n). The Prescriptive requirements do
not allow the installation of a recirculating water heating system for single dwelling units.
3. The external water heating tank and i es shall be insulated to meet the requirements of §1506).
SPECIAL FEATURES The enforcement agency should pay special attention to the Special Features specified in this checklist below.
These items may require written justi nation and documentation and special verification.
NEW ROOF ASSEMBLY - Radiant Barrier
The radiant barrier requirement of §151(02 does not apply to roof alterations.
Slab Edge (Perimeter) Insulation ❑ YES ❑ NO
YES: In Climate Zone 16 in Component Packages D, R-7 insulation is required.
Heated Slab Insulation ❑ YES ❑ NO
YES: Slab edge insulation required for all heated slabs in all Climate Zones. See details in Table 118-A of the standards.
Raised Slab Insulation ❑ YES ❑ NO
YES: In Climate Zones 1, 2, 11, 13, 14 & 16, R-8 insulation is required; in Climate Zones 12 & 15, R-4 is re fired under component Package D.
Thermal Mass �O �j►32_
To obtain Compliance Credit for the installation of thermal mass, use the Performance Approach.
Registration Number:
2008 Residential Compliance Forms
Ui i Y yr L/A UU11v I A
BUILDING & SAFETY DEPT.
Registration Dale/Time: FGW0 I TRUCTIO—
Azrgzrsl � 09
DAtE 105 Y
Prescriptive Certificate of Compliance: Residential CF -IR -ALT
Residential Alterations Page 5 of 5)
Project Name: ; Climate Zone # # of Stories
HERS VERIFICATION SUMMARY The enforcement agency should pay special attention to the HERS Measures specified in this
checklist below. A completed and signed CF -41? Form for all the measures specified shall be submitted to the building inspector before final
inspection.
Duct Sealing & Testing HERS verification is required for this measure.
❑ YES ❑ NO YES: In Climate Zones 2 and 9-16, if more than 40 linear feet of new or replacement ducts are installed in unconditioned
space, the ducts are to be sealed per § 152(b)1Dii and the newly installed ducts are to be insulated per § 151(010.
❑ EXCEPTION: Existing duct systems that are extended, which are constructed, insulated or sealed with asbestos.
❑ YES ❑ NO YES: In Climate Zones 2 and 9-16, if the existing space -conditioning system (HVAC equipment and ducting) is replaced, the
ducts are to be sealed per §152(b)IDi.
)2QES j:� NO YES: In Climate Zones 2 and 9-16, if the existing HVAC equipment is replaced (including the replacement of the air handler,
outdoor condensing unit of a split system, cooling or heating coil, or the furnace heat exchanger) the ducts are to be
sealed per §152(b)IE.
❑ EXCEPTION: Duct systems that are documented to have been previously scaled confirmed through HERS
verification in accordance with procedures in the Reference Residential Appendix RA3.
❑ EXCEPTION: Duct systems with less than 40 linear feet in unconditioned space.
❑ EXCEPTION: Existing ducts stems constructed, insulated or sealed with asbestos.
Refrigerant Charge -Split System HERS verification is required for this measure.
❑ YES ❑ NO YES: In Climate Zones 2 and 8-15, when the existing HVAC equipment is replaced (including the replacement of the air
handler, outdoor condensing unit of a split system A/C or heat pump, cooling or heating coil, or the furnace heat
exchanger) a refrigerant charge measurement shall be verified per §I52(b)1F.
Central Fan Integrated (CFI) Ventilation System and Fan Watt Draw
The ventilation requirements of §150(o) do not apply to existing residential homes.
Ducted Split Systems -Air Conditioners and Heat Pumps: Airflow HERS verification is required for this measure.
❑ YES ❑ NO YES: In Climate Zones 10 through 15, when the existing space -conditioning system (HVAC equipment and ducting) is
replaced, the airflow and fan watt draw shall be verified per §152(b)1Ci to meet the requirements of §151(07B.
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and complete.
Name:
Signature:
ompany :
Date:
Address:
If Applicable CEA or ❑ CEPE
(Certification #):
City/State/Zip:
Phone:
Responsible Building Designer's Declaration Statement
• I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the building design identified on
this Certificate of Compliance.
• I certify that the energy features and performance specifications for the building design identified on this Certificate of Compliance conform
to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations.
• The building design features identified on this Certificate of Compliance are consistent with the information provided to document this
building design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building pen -nit application.
Name:
/1?i0_
Company:
(i2vnr�t2
e:
. 61a,110
Address:License:
53-333 �ri��t� ��iAz
City/State/Zip:
LA �t-c�N �i¢_ %Z
Phone:
76o -Q9-1,075
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at. 1-800-772-3300.
Registration Number: Registration Date/Time: HERS Provider:
2008 Residential Compliance Forms August 2009
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