0401-068 (SFD)r LICENSED CONTRACTOR bECLARATION
•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
/bate"'l- 1Z/Signature of,ContrOctor� 7
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' rofes6onals Code).-
( ) I, as owner of theapropertys am exclusively x tracting with licensed
contractors to constru%lt 1prdject (Sec. 7044! business & Professionals
Code).
( ) I am exempt under'Sectton 4 B&P.C. for this reason
Date iSignaftuie of Owner
WORKER'SOMPENSATION DECLARATION
I hereby affirm under ,p,enalty ofdperjury one o fAhe following declarations:
() I have and will mairStain; certificate of cons9nt to self -insure fo ,.workers'
compensation, as provided f6r by Section 3700 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 f*XjF.,MPT Policy No.
(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 37760of the Labor
Code, I shall forthwith comply with those tr visions.
Date -1._ f2 ,n / J((pplicant , P11 -P 7` 5,� (52
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.
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 r inspection purposes.
gnature (Owner/) t)
--�� / Dat/.�
-
BUILDING PERMIT PERM's#
•�' '
^
DATE ! - VALUATION. t LOTLOTTRACT i 7
JOB
ADDRESS 'J24"k:�f/ AVIE. .�'E�.Li�WUM
Al - 'i lam.' . b. .�-� •' " r'' ....
OWNER
CONTRACTOR / DESIGNER / EN (NEER'
LEG_i�cy 1-10 WS
54.865 AV1_`fd1nA O'B 'EGON
P.O. BOX 696 : r
LAC)I1'iA j Cis, 92253
1qtM'A Cls. 92253 ;
\
(760)564-7820 ; C51.4 02063
�'
USE OF PERMIT 4
1891 S.Y. SVD PERMIT DOES'NIDT 114CLUDE, BLOCK WALL, POOL/SPA � r+•r
OR 1Jl 1VT&WAY APPROACH .,
TRACT CONSTRUCTION 1,851.00 OF
� �•:.;
PC".RCH/PATIG 133.08 SF
tl.ARAONCARPORT 469.00 Si?
y'
'j
M/.CA`C`L'.C1 COSTOF COINSI'RU( Ir ON
111,497.203'
FERMI' FEE SUMMARY
4
CONSTRUCTION FE? 101.0004186-000 x;603.50
PLAN CHECK. nrE 101-000-439-318 $365.14
.
FE.E DEPWIT 101-000-439-318 4250.00
•_
Ife FCHAAIICAL FEE, 101-000-•4.21-000 $99.00 '
)2LECTR.IC,AA1., FEE 101.000-420.000 $122.67
t
•°
PLUM BIN 0 YE EP 101-000-419-000 $130.00
;•
STROM) MOT [ON ILEI;.- RLSID 101-000.241-1100 $11,15
ORADrH0 P70 101-000-423-000 $15.00
DEVELOPER IMPACT FFI $2,405.00
PRECISE PLAN $100.00
•'
SUB -TOTAL L0N .UC`n0W AND PLA14 0MCK
$4,089.51, ^�
LESS PRE -PAID 1?XES
4250.00
i� JAN 3 0 2004
� >hjy t_i �l (•tlA
RECEIPT
DATE /
BYC f_
DA A
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs L
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck —
Exhaust Fans
O.K. to Wrap_
F.A.U.
Framing l� O
Compressor
_
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall - Int. Latham%�
Final
Final O
BLOCKWALL A ROVALS
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
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
,Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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 - �=
Final
Utility Notice (Perm)
COMMENTS:
414
f��itrGv
'1� P.O. BOX 1504 APPLICATION ONLY
C LLE TAMPICO
Building �� O �,Ai t , -
Address � �l GLG�-
8 495 A
� LA QUINTA, CALIFORNIA 92253
Estimated Valuation
Owner
.Io k(FIs
PERMIT
AMOUNT
Plan Chk. Dep.
-S-D �-
Mailing
-�,
Const.
BUILDING: TYPE'CONST. OCC. GRP.
Address
Electrical
A.P. Number
Plumbing
City
���✓vim
Zip
�
TeIG�s�/�
��jj
T Legal Description W �J -
i
6IkG- 7 -7
Contractor
CITY OF LA
CE DEPT
A� _/
Project Description /V>uU Gd]T
_
A,dddress
REMARKS
/�✓r L
!L
V p i3
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 Permit
Validated by:
Validation:
' ity
iQ.L �
Tel..
Sta a Lic.
& Classif. T� �' ��
City
Lic. #
Sq. Ft. No.
No. Dw.
Size Stories
Units
Arch., Engr.,
Designer 01
New Add ❑ Alter ❑
Repair ❑ Demolition ❑
Address
Tel.
City
Zip
State
Lica #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 licensed under ovisions of Chapter 9 (commencing withSection
7000) of Division 3 Business a ass' ode, and my license is in u11 force and
effect. / %%% / s31
k— OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031. 5. Business' and.' Professions Code: Any city or county which requires a
permit to construct, alter, 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 that. 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 (8500).
I': I, as oner 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'1 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'? I 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
F1 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of for which his permit is issued, I shall not
emplo��4
pery manner come su to the Wo ers' Compensation
Law
Da
N TIahe makingthisCertllica1.oprionushould Decomesubjectto Workers' Compensation provisions of the Labor Code, you mustforthwithcomplywithprovisions or this permit shall be deemed reroked.
CONSTRUCTION LENDING AGENCY
1 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, and is subject to
expiration it 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 slate laws relating to building
construction, and hereby authorize representatives -of this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address,
City, State, Zip
WHITE = BUILDING DEPARTMENT
YELLOW = APPLICANT PINK = FINANCE
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
-S-D �-
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading,
Driveway Enc.
Infrastructure
d
O0 Z003 Bull
CITY OF LA
CE DEPT
TOTAL
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 Permit
Validated by:
Validation:
YELLOW = APPLICANT PINK = FINANCE
Date 1/29/04
No. 25431
Owner
Randy Bills
Address
54-865 Avenida Obregon
City
La Quinta Zip 92253
Tract #
BLK77
Type
Single Family Residence
Lot # No. Street
Unit 1 21 52060 Ave. Ramirez
Unit 2
Unit 3
Unit 4
Unit 5
Comments
CERTIFICATE: OF�COMPLIANCE
Deseri.3ands Unifed' School. District
47950; Dune. Palms Road
La Quints, CA`'92253
(760) 7.71-8515
Q BERMUDA DUNES
U) RANCHO MIRAGE
INDIAN WELLS
�.� PALM DESERT y
LA QUINTA
%IN0 N^
O J
S.F.
At the present time, the Desert Sands Unified School District does not collect fees on,garages/carports; .covered patioslwalkways, residential additions under
500 square feet, detached accessory structures -(spaces that do not contain faciiiiies'for Iwing,;: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 11620: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 C/C-1St Bank, Shardn Bills, Check No. 70903
Name ori -the -check Telephone; 880-3446
Funding . Residential
By Dr. Doris Wilson
Superintendent
Fee collected
Signature
Payment Recd
$37961.14 Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 9"ay 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 Disirict('s) behalf, whichever is earlier.
NOTICE:, This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
APN #
773_=222-022
Jurisdiction
La Quinta
Permit #
0401-068
Study Area
No. of Units
1
S.F.
Lot # No.
Street
.1861 Unit 6
Unit 7
Unit 8'
Unit 9
Unit 10
S.F.
At the present time, the Desert Sands Unified School District does not collect fees on,garages/carports; .covered patioslwalkways, residential additions under
500 square feet, detached accessory structures -(spaces that do not contain faciiiiies'for Iwing,;: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 11620: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 C/C-1St Bank, Shardn Bills, Check No. 70903
Name ori -the -check Telephone; 880-3446
Funding . Residential
By Dr. Doris Wilson
Superintendent
Fee collected
Signature
Payment Recd
$37961.14 Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 9"ay 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 Disirict('s) behalf, whichever is earlier.
NOTICE:, This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
RC .DISTRICT PLANNING REVIEW `FORM
This form is 'to be used by ".CDD staff for review of single family dwellings in the RC '(Cove
Residential) District per Section :9.50.090, of .the Zoning 'Code.. Its purpose is to. determine; 1)
that the proposedhousing,design does: not -duplicate the same architectural style of any house
within. 200 feet of the applicant,. and/or 2) if there is -'e' a nd forthe applicant to file for Master
Design Guidelines. If the applicant does ne'ed-,to`file a Master"Design Guideline, please transmit
this information to the Bui.ldirg and. -Safety Department as part of your correction list. Please
attach additional explanations as necessary.
APPLICANT:'
SITE ADDR22EE,
-7
APN 7✓ -�40k,�A - U U1_11 --
CASE NO.: %i
LEGAL: LOT f BLOCK Z UNIT _
CHECK AND APPROVED.BY:
S.C.@V.L.Q.
DATE:
Inform the assigned Building plan checker upon yourassignment to this
case. The CDD .
Executive Secretary maintains a log book to track applications and assign case numbers:
REQUIRED ITEM
Y, N .
COMMENT/CORRECTION
Verify legal and APN information
Consistent with MDG on file .(as
applicable)
.MDG filing required (5 filings
since 9/3/98)
Architectural variety within, 200 .
feet of the surrounding area:
VA
II "
Architectural design features
Other Requirements:
-
r
Pla
ed .b at es
Hing'. ommission ----
Gase,
xhib
Wit
mu ept:
4 o:"
1
Conditions
tl
r
a �9addanEn��nsariing
8782 Stantori Ave., Suite A, f ha Park,, GA -90621 (714) 523=095? `Fax (714) 523.1.3t39
39-725 Garand Ln., Suite.G, Palm Desert, CA 92211 `(760)-772-3893 Fax (760)`772.3895
Date-
Job
ate-Job No. —�
000795
;t
FIELD,-1VI'EMG
Project Name Client:
Site Address
Job Phone.
WOW oone n
OU
Comments
r.
Field Tech. Super. or Agent
24 hour notice requested to -schedule Field Technician. Thank you for the opportunity to be of service_
Z d 60LOLLZ089 'ONAS 8 '1S/b£: 8' bOOZ 64, 933 (OH1) 1,183S30 WIVd N300b1S W081
Test Summary / Footings Inspected'
Test%
No.
Location :. I �lev.
Ory
Density.
Moist
'/o -
% Relative
Compaction
Ref. Max Moist
Pcf %
.3 2.
7 L��'.
OU
Comments
r.
Field Tech. Super. or Agent
24 hour notice requested to -schedule Field Technician. Thank you for the opportunity to be of service_
Z d 60LOLLZ089 'ONAS 8 '1S/b£: 8' bOOZ 64, 933 (OH1) 1,183S30 WIVd N300b1S W081
-15-2ee4
CERTII]
07:10 AM
TE,
NGS
Plan Number
Sample drouo Number
Sample Houae Number
rider: �/ C. •�' ����•/tiffs
Street Address: 7,01'idJ4,City/State/zip:
Copies to: Builder, HERS Provider
IERa R TE MP �iI 51'A ET MEAT
The house was Tested` ❑ Approved.as part of. Sample testing,. but was not tested
As the HERS rater rovidin d�agnostI testing and field 4hflcadon, 1 cert1, that -`.the houses Identified on this form
com y with the diagnostic tested compllahes-requlrements�as checked, on hi$ form.
Distribution system Is fully.ducted (1.e., does notuse building cavities as plenums or platform returns in Ileu
of ducts)
Where cloth backed, rubber adhesive duct tappjs Installed; mastic and drawbands are used in combination
with cloth'backed, rubber adie'sive dut t.tape10 seal leaks at duct conneolions,
MINIMUM REQUIREMENTS FOR DU'dT LEAKAGE,REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Resulto (Maxlmum�0% Duct Leakage) .
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
P.02
2,
Test Leakage, -Flow In CFM
if fan flow is calcuiated:;8s='400cfm/ton'x number.of tons enter
calculated value here
If fan flow is measured enter meas,,red value"here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fail.(Pe69.0 a% or less)
THERMOSTATIC
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent);isInselled and Access isprbvided for Irispectlon
Yes is a pass
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
❑ Yes ❑ No ACOA Manual D Design iequlrementsthbve=been met
(rater hes've'rifte"thatActual-irtistallation;metchas values in
CF -1R and design on plan.
❑ Yes 17 No TXV is installed,or Fan flow -has been verified. If no TXV,
verified.fan'-flow'matches_deslgn from CF -1 R.
Measured Fdn :Flow =
Yss'for both.'I and 2 is a Pass
or
valent
�i
rass Fail
R�-Q
Pass Fail
D Q
Pass Fall
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er"t-1 ,tcate�'�juf
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This ZeiWrWte 4s'-4ssLred,4pursuanVf6. e��"reauiremenrs..�6f-Section� 1016f ttie�,,Califdriiia'Biiilding:���,-,�
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A4 ZIP -,,:L-A,QUINTA 92253
ByfSTEV ETRAXEL
.2, �
ne,21!' 2004*
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