0202-151 (SFD)W
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LICENSED CONTRACTOR IIECLARATION
I hereby affirm under penalty of perjury'that I' am licensed under provisions of
;f*ter 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 Exp6ate
/Date ''"zo .'o? Signature of Contractor r
OWNER -BUILDER DECLARATIO�4,,,(7 e�d'y,,v
I heieby affirm urdw perially of perjury that'( am exempt fruill the Contractel•rs
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).
( ) 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
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 1'1'A�T'1i' FU34D Policy No. 3�Srf��-t10996'�1
(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 Se6tion 3.700 of the Labor
Code, (shall forthwith comply with the se�prov_i.giops.� +may p1Ja
Date: Applicant
Warning: Failure to secure Workers' Compensation coveragessfu'nlawful and
shall subject an employer to criminal penalties and civil fines up t '_00,000, 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, indemnifyy
& 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�represbntatives of this City to enter upon
the above-mentioned property,far`ip. spe2,ti6ri j�u caes
Signature (Owner/Agent) D6i-e
BUILDING -PERMIT. PERMIT #
DATE �d.b�rAT'sa7.R�-
VALUATION % LOT' - TRACT. � •ra. a 6 • �. a1.111,25 .
JOB SITE, " ` APN
OWNER
CONTRA OR/DESIGNER/ENGINEER
UWMS PO7:i WILK
Lto�l`.�U V MORES, WC,
PC) WY 450 -
`18-1.'20 CA1 •VK E',T 204
:�A Qr" (NTA Cts 922:53
TA QT )NIA CA, 922253
USE OF PERMIT
SM F PFRMIT DOM tril~`IT 12dC1..UDE, RLOCIC WE U. , P001. OR1`3C't.'.'f<"'LYi+�'AY
,APPROAB.`K 98 C,`OD&
i�
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TRACT CONwTRU`,ITION 119,13.00 :dP,
PC?3�tS�GA1-UY,ir�AT.i9tb723e�
tw fi�rtl�.lo C�[SIP
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wKM C091F OF coffirX.RtrMON
31.4,57-1.
$3 y�ry9 �tt p�yy �g•y:I?�l:
COrtla'i".'��'UCT ON HIM' 10) -000-418-000 $092,00
PLAN CH&NC FEEF, 101-000-4i'19-319 PYA -44
1ER MPOSIT 1:01.000.43.4-318 471.50AI
' E
N11�,+
8101-Qf�.t0-4-2r1-/G�i10 p.$161.00t
gA''NICA„/g3.1�.yy�;.
IX
'r PLIU1%1k3RNOYao. 101.•000.419.0-00 $1:36,00
STRONO MCs?.'1M FEE - RPS M 101-000"241- 31.1,46
(IRAI 1A O ME _1423 -fes{) $20.00
rAVE1:,CPER IMPACT F&E $1,907.00
PRECISE PLAIN 1t"f���itttS»�4•�•�`1� $100:t1Ei
KHS-TOTAL C� t't.Tf.'x" OX AM)3)?y1:.13�1'�Ggi��;p�: t
$3,,62S.
,Y�(�ty
/S•�r1t
a.
Aug 1" fi l' 11 M DUEe .NOW
MAR 2 U' 2002
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WY®FIAfJlUI Ay
FRY z: •.
RECEIPT
DATE / p
BY
DATE FIN LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
or Zf,,Return
Air
Steel
Roof Deck
/0
ombustion Air
• , aust Fans
O.K. to Wrap
_
F.A.U.
Framing
r
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
oe
Final
Final
0 3 57
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
,Q i
f �� �`�`�'7
Heater Final
Water Piping`f
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
– 12, . Z —s
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL JPPROVALS
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
K,`` G Q�
Final
Utility Notice (Perm)
Q
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 3/19/02
No. 23060
CERTIFICATE OF COMPLIANCE
APN# 774-175-018
Jurisdiction La Quinta
Owner Name,Dennis Pollaccia
No. 53865 Street Avenida Bermudas
City La Quinta zip 92253
Tract # BLK251
Type of Development
Comments
Lot #
Single Family Residence
Single Family Residence of 1913 sq. ft.
Permit # 0202-151
Log #
Study Area
Square Footage 1913
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined 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 Government Code 53080 in the amount of
2.14 X 1,913 or $ 4,093.82 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 2 Money Orders and CC BofA/Anna Gonzalez Telephone
Name on the check
By Dr. Doris Wilson
Superintendent -
r _
Fee collected /exempted by Crystal Scott Payment Received •-$4,093.82
Check No. 2011293102
Signature 6d4
VOTICE: Pursuant to Assembly Bill 3081 (CHAP 549, STATS. 1996) 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 sssued or on which they are paid to the District(s) or to another public entity authorized to
:ollect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
CERTIFICATE OF FIE
P. 02
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Builder Name
Plan Number
Sample Group Number
Sample House Number i
Firm: .J .C. HERS Provider: Z1.0 4 ,,o01r'S-Vd61
Street Address: ZZaa &&ZE-OKI C kYb6w CitylSlate2lp; L4 ORInfai 6/f qAZ� 3
Copies to, Builder. HERS Provider
NESS RATER COMP616UQE- AT MENT
The house was; XT08ted ❑ Approved as part of sample testing, but was not tested
As the HERS rata, providing diagnostic testing and field verification, I certify that the houses Identified on this form
cowith the diagnostic tested compliance requirements as checked on this form.
Distribution system is fully'ducted (i.e., does not use bullding cavities as plenums or platform returns in lieu
wZ ducts)
here cloth backed, rubber adhesive duct tape is Installed, mastic and drewbands are used in comt�ination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM 'REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 26 Pa) values I
Test Leakage Flow In CFM
If fan flow is calculated as 400cfm/tor 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) =,
Check Box for Pass or Fall (Passz6% or less)
THERMOSTATIC EXPANSION VALVE
7—
I or Commission a
ivalent
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
Q Yes ❑ No RCCA Manuel D Design requirements have been met
(rater has verified that actual installation matches values in
CF -IR and design on plan.
2. ❑ Yes ❑ 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 t and 2 is a Pass
4�
Pass Fail
i
ass i Fail
1
AIM
I
O ❑
Pass Fail
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0 Certificate of Occupancy0 .
4
r.�r'M
C� OF'TBuilding & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 53-865 AVENIDA BERMUDAS
Use classification: SFD Building Permit No.: 0202-151
Occupancy Group: R-3 U-1 Type of Construction: VN Land Use Zone: RC
Owner of Building: DENNIS POLLACCIA Address: PO BOX 450
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
1 Ad's Date: 12-24-2003
Building Official
POST IN A CONSPICUOUS PLACE