0211-169 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
CY
r— LLI s Inc
Z � Datef _ /�J' 1 Signature of Contractor 7 / /yn,
r` b
J OWNER -BUILDER DECLARATION
W w 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).
M ( ) I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
D)
d Q WORKER'S COMPENSATION DECLARATION
o 2 Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CD Q () (��) I have and will maintain workers' compensation insurance, as required by
O U Q S98tion 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier �`lSA%F Policy No. 2��91 AlPi1'?fS'7i
ob
0
J (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. I _
Date: Applicant ` ) 7
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
r�Vip & 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.
1 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. .� _
sSignature (Owner/Agent) i f' "' Date f
BUILDING PERMIT PERMIT#
DATE VALUATION LOTif.�� TRACT
JOB SITE
ADDRESS ! 6v6 DA: : �.'ff 1 9.f�
APN 'T74 --I 'l5-019
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P.0. B, GX. 454
78.120 CAL.TZ MADO SIXTE 204
i..AqUOTFA CA 92253
1.A.C1tYiWA CA 92253
p5Uy 564- i i366 CBIJ* $59
X ANI)FL VeNTUR..k % Ne-
USE OF PERMIT
,g1NQ44L , FAIVOLY D•W,>r.,LX WGI,
78-120 Ck= k..,T.ADO SUITE 204
51I) - 1399 SQFT. PE01IT DOES NOT iach;ds Block Wall;
Fewra, Vaal or Ups, A xepsa A Diivvw,4 Apprevuh Paw. A is
nr:gar`rvsrl fi the 11111fic Work's X3vpviTnr-nt.
TRACT CONO'€'RUC T IOrki 1,8$9.09 UP
PORCkUPA 10 7.16.W SJr'
QA,R.A0E.s'C %1RP'0R 491,00 OF
0014 TRUCTK'*-I ftg 101-000-418-000
KAW CHF4K I= 101. _000.4.391 31 a
1ZE f EN *1`1T 101-000-439-318 42$010
MECHANICAL Ipl,i:. 101-000-421-000 $92. A0
ELFCTRIC.AI., FRZ 101.000-420-000 917*79
PL'U.ItItCiP3 O "Z 10 1 -D00-419-00 $119.50
STT;.t NO MOTION RE - RUID 01-000.241.000 S;,LS6
101.000.423,000 $15.H00
t�rgO MDt3a9=p
Ov�}r�.R�
41 7 L� �}
DIC R7r�af. PER A67'�Z'AC FFFiJ9 $2.40,50 l•
PRECIS K PLAN 101-000-441.345 !�1I2f3.Ot!
S4,170-33
D A\ 1X33 PRZ--PAW :k�i�:l • X250, 00
A:�.;� M.M. : I's DUE 111 ow H020.:3
FEB
2 7 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DArT�E p
BY"'
li f
DAT7INAlED`U�
INSPECTOR'S yJ
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs , aJ3
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
_ _
Roof Deck /-
Exhaust Fans
_
O.K. to Wrap -
F.A.U.
_
Framing / /_ OG _
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
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
Gas Piping
PLUMBING APPROVALS
Gas Test_
Waste Lines �i ,� 0ue� zf
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral_ _
Sewer Connection��Q-� -
Pool Cover
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 �/j _ d
Final
Utility Notice (Perm)
CERTIFICATE OF COMPLIANCE J�, �D�,
Desert Sands Unified School District z4�"s,o
47950 Dune Palms Road
Q BERMUDA DUNES r
rn RANCHO MIRAGE d
Date 2/26/03 a uinta, A 92253 INDIAN WELLS
DESEFrr
No. 24183 (760) 771-8515 t, PLA1UINTA
� NDIO
0
Owner Dennis Pollaccia APN # 774-175-019
Address Jurisdiction La Quinta
City Zip Permit # 0211-169
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F.
Unit 1 453885 A_v_enid-alBermudas=1899 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
Lot # No. Street S.F.
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 (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 1,899 S.F. or $4,063.86 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 CC/Bank of America - Anna Gonzalez Check No. 2013928231
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey $4,063:86 $o.00
Payment Recd Over/Under
Signature C
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
LC 111110 , MUNIMS, INC.
July 30, 2003
CITY OF LA QUINTA
P. O. Box 1504
78-495 CALLE TAMPICO
La Quinta, CA 92253-1504
RE: 53-885 AVENIDA BERMUDAS
PERMIT NO. 0211-169
Dear Sir:
At the time we have completed grading of the property and installation of the boundary walls.
We have delayed starting the construction of the residence awaiting approval of a construction
loan for our client. The lender Hammond Securities has just recently approved our client for
their loan. We believe it will be approximately 30-45 days before the loan is recorded.
We are requesting a time extension of 90 days for the above permit before commencing with
construction of the residence.
Very trul,.y yours, _....
LEN DEL VENTURES, I
Preside
APL:vI
Enc.
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED'
P PROVED l
DATE 'S BY
P. O. BOX 450 * LA QUINTA * CALIFORNIA * 92253-0450
760/564-1866 * FAX 760/564-2627
TESTMG CF -4R
oete
Bus48rNeme
P18n Number
Sampte`Group Number
Sample HouserN�umber
Mar.
Street Address, 7 �l0 �' �✓f fp-�& City/Statelzlp:
Copies lo: Builder, HERS Provider
HERS RATER CQMENCE-TATIMENT
The house was: Tested D Approved as part of sampilbAesting, but was not tested
As the HERS rater provldin alagnostk testing and field verification. I ortlfy that the houses Identified on this form
comylr with the diagnostic ested compliance requirements as checked on this form.
Z Distribution system Is fully*ducted (i.e.. does not use building cavities 'as plenums or plajttorm returns in lieu
of ducts)
Where cloth banked, rubber adhesive duct tape is Installed, masUe end dra~ds are used In combination
with cloth backed, rubber adhesive duct tape to seal leaks at duet connections.
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Ouct Olagnostic Leakage Testing Results (MaxlmuM'1111 L Duct Leakage)
Measured
Duct Pressurization Test Results'(CFM Q:25 Pe) values
Test Leakage Flow In CFM
If fan flow is calculated as.40pcfm/ton.x.number.of tons enter
calculated value here
emlIf fen flowls:meeu>ue here
Leaked Percentage. (1;00 x 7est:Leaka>ipe/Fan•Flow) = :J.
Cfieck-a3ox=for-Pase::or. Fefl (Pass=696 orless)
or ❑
Pass Fall
THERMOSTATIC;EXP„AN,StON VALVE„ .� ; :ar.,Comniis�ons , , ved:e. uivBI nt .
Yes ❑ No Therm'oMtalit E ipanslon .V, ve .(or Commission approved
equivalent) �s;�nstatied?a3nd Access asprovldedfo� insperUon
❑
Yge fit-a;pess
Pass Fail
❑ MINIMUM REQUIREMENTSfOR'DU.CT`DESIGN'CQMt?LUWC,E.C:REDYf
1. O Yes O No ACCA:Nlanuel0Destentroqulfements.heye betfl met
(rates heswe Nled tt at:ecfu F ristallation matches:values In
CF -1R and desIcn-on::plen. ).yQ
l y V
2. 0 Yes O No TXV ISJnstalled or..Famflasw-.h ::been verified', If no TXV,
verifled'fan flow matches design from CF -1:R,
Measured Fan Flow =
O O
Yes for both 1 and 2 is a Pass
Pass Fail
Certificate of Occup'ancy
wr
G4 4i�
o9Building F g &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: 53-885 AVENIDA BERMUDAS
Use classification: SINGLE FAMILY DWELLING. Building Permit No.: 0211-169
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: DENNIS POLLACCIA Address: P.O. BOX -450
City, ST, ZIP: LA QUINTA, CA 92253
d % By:. KIRK KIRKLAND
Date: August 4, 2004
Building Official
POST IN A CONSPICUOUS PLACE