0210-195 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
�N LU Professionals Code, and my License is in full force and effect.
C =) M License # Lic. Class Exp. Date
O 751812 B 07MM
oZ r-- Date Signature of Contractor
c„ O.11�
J U to
0 OWNER -BUILDER DECLARATION
WUJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
Cf) () I am exempt under Section , B&P.C. for this reasr A
O N Date 11 QQ1 Signature of Owner J1..� d
rn
d Q WORKER'S COMPENSATION DECLARATION
o 2
cc I hereby affirm under penalty of perjury one of the following declarations:
Lo r � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W I = compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance'of the work for which this permit is issued.
m QV iO I have and Will maintain workers' compensation insurance, as required by
Q U Q Section 3700 of the Labor Code, for the performance of the work for which this
10�Acmr<;Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier STATE FUND Policy No. f400 9901
cb5ry
r- V
Q (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: A,
Applicant r f„, o
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 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. s.
ro .
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 i
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) ��• - f Date
t:
BUILDING PERMIT PERMIT#
f
DATE/ t VALUATION LOT 0210-195 TRACT
i_10
JOB SITE �y�p�a �p� yq
ADDRESS �9�{i� �.se3CR.1SRf.�qveZOA.
APN
OWNER
CONTRACTOR/DESIGNER/EN INEER
0)BF. tiTARD O
$14 (11JII:M f.:0X9Mi:i\,"TT01q
R&Oi_3N1AW ( 7' YR CA 911561
(Wi, )349.9025 G Ia6E 3; k�5
_
USE OF PERMIT
EMIG :.1? F.00t.`Y' mmu"G
185k S.F. St D f:'EAW)IT DOW; NOT r9ZLUDL 91.C.CK: W IAN, POf.: L OR.
LAWWAY APPROACH
TRACT C'ONSTRUCT100 I131%1.0 B
PORC:k't P.A!r10 98.00 OF
OARA.WCA.RPORT 469,40 SF
COST 03F CIO2* 1'RUC170H
'g=qJIMTKID
.i�.iS�B4.4YZhi 37 I'a�`. �EJdYJl:1o./.f�JR B�
COM;.I'7'RUIC3'IO.V411 I()1-000.418.0130 $081,119
P1,AN C(FlFr,K Kl' 101-tAW-439-319 063.69
IU DEPOSIT 101.000.439.318 425010
DAM, HANI'C.A,L YE? 1.01 _0040421 000 V59.00
Lf1,XCTft.ICAL. Z 101.000.420-000 %1112.67
,PLUSH BINGI FFN 101-3.00-•419-000 $124.00
S"{R;�,t?QCs MOTION IFFE' - ROD 101-00 0.241 *000 S1. 7.10
OR")NO Fitz 1(11-000-4%3.7'70'7) W.00
DEVELOPER IMPACTM, smos,00
P..RW3S1'.PLAN 101 -WO -441-345 W1i7(3.0d
..t
Y.11112 P1LVePA=Y'FP1R3
4260,00
Nov I)
CITY OF LA QUINTA
FINAHcFnFPT
RE BY`� DP� _1 D INSP
/�
/� "•""
TOR
r ? F y " .. �. - V l
t '1 ..
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
6. 03
F.A.U.
Framing
, C7
Compressor
Insulatione7
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 Covet
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
U 2_ �- �
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
COMMENTS:
Final
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 Z� v�
Final
_
Utility Notice (Perm) %'
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,851 S.F. or $3,961.14 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By OC/EI Paseo Bank - Ed Bernardino Check No. 023684974
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Monica Guillen $3,961.14 $0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant ' Copy - Applicant/Receipt Copy - Accounting
APR -17-2003 01:18 PM
Fla
Rater
M
Pirrtitying Signature Or Dane
Firm:.TC. d- SS DG/�6eS
Street Address:
.F,� k/Jy fd3
CF -4R
Plan Number
Sample Group Number
Sample House Number
HERS Provider: —TC -,L efir:gd6l S
city/State/Zip: ZW 2(fl,416 60 wsa
Copies to: Builder, HERS Provider
HERS BATIR CO_MtLlkkNCC SIATJMINT
The house was: Vested ❑ Approved as part of sampie testing, but was not tested
As the HERS rater providing diagnostic testing and Heid verification, I certify that the houses identified on this form
comoy with the diagnostic tested compliance requirements as checked on this form.
Distribution system Is fully'ducted (i.e., does not use bullding cavilies'as plenums or platform returns in lieu
�f ducts)
Where cloth backed, rubber adhesive duct tape Is installed, mastic and drawbands are used in combination
with cloth backed, rubber adhesive duct tape to seat leaks at duct connections.
2l MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM ti
if fan flow is calculated as 400cfm/ton x number of tons enter
calculated value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) , YA
Check Box for Pass or Fall (Pass=6% or less) ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Conunission approved equivalent
Yes ❑ No Thermostatic. Expansion Valve (or Commission approved
equivalent) is Installed and Access Is provided for Inspection
Yes is a pass
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. O Yes O No RCCA Manual D Design requirements have been met
(rater has verified that actual installation matches values In
CF -1R and design on plan.
2. 0 Yes D No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
Yes for both 1 and 2 Is a Pass
D
Pass Fail
D— O
Pass Fail
A-1 Cesspool Service, Inc.
P.O Box 58018K North Palm Sprbg% CA. 92258 JOB INVOICE
`Since 19591
(760) 329-6875 Fax (760) 251-3405
State Lic. #265214
www.alcesspool.com
BILL TO
GERV10E 13 PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUO UPt ❑ Yos ❑ N9 ❑ PMr. ON SITE
REOUEOTM 0 PUMP SEEPAGE PITAT ITS RISER
[] OFFICE i3iLLItrG
UUANL DESCRIPTION O PRICE APACLNT
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee Qhr. Min.)
Out of Area Fee
El THE LEACHING SYMM HAS PAM.
0 THERE IS AN [ BFMUCTION "UPSIREAM"OFTHE SEPTIC TANK
a�vEl hetn c>xnwsa s�eiesnm$aomp�y.
0 WERECOMMENDMARIrMMCEPUMPINGOFTf BUffICTANKBVERY
❑YEAR 13 OTHERYF1a ❑ 2.3YEARS
TomombWhips6ds. This willhxasel4cLife ofy=k&ditsys1w.
p TMSPUs4PINOWQ.LPROVmEONLYTRMPORARYRE mFANDNOT
SOLVE CUSPOMERB SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSrOMER HAS BEEN OIVEN AN "wLAINATION' PACKET.
ASERVICE CHARGE OF 02 WILL BB DUE
ON ALL RETRUNED CHEM
A FINANCE CHARGE OF 11a% PER MONT9,1i% PEE YEAR WILL BE
CHARGED ON PART DUEACCOUNrS OVER M DAYS.
IF PATMENr IS BY CHECK
DRIVER;9 LIC. N-Si'ArE
I benkr aekcorrkdgstlr aas6aaq eaepxaoa:tme.bow desalbea,
SIGNATURETotal
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