0203-037 (AR)LICENSED CONTRACTOR DECLARATION
,J 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
44750: ( B .I;T1 t:
Date Y�� (+OSignature of Contractor
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 & 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 BT. TR". 144 Policy No. 9442188
(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 S'ction 3700 of the Labor
Code, I shall f hwith comply Wi1h:•th so a pro isions
Date: t� Applicant'
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 inspection purposes. �1
,Signature (Owner/Agent) /``—'0===" �'° Date3
'BUILDING- PERMIT FERNY#
DATE 03Ao�Ca VALUATION vW952go LOT TRACT
456,01
JOB SITE
APN
ADDRESSM,f - -E rZ
Wl
�'75-241-01 e
OWNER
CONTRACTOR / DESIGNER / EN (NEER
DONAIM E: TEL:�iOW
3.3W3.C. N .Bulu"N A!SS:.!~ INr
5.5- fi 0��P:Iq�3dL��? )RZI c
��'yr�4, -3�3f3 U- ,�t'��;.����5r'tO STJYYL,' 4.1;1
,g 9
L,�; t� 10.0.NTA CIA 91 2 5 3
PAMIIFI "&?i i41 CA 9.2'260
(7!60):346-5300 C'1au :i3END
USE OF PERMIT
.' IN,UDI 'I7.,A.. l it v a
420 Str'.P3'i"F.FsCHFJ;) GUFST SUITE WITH W SPADL)1'P1C+ttf#tF;mUt.1m. of
OARAOX HOA.&PPROVAL 0114 FUR
CUSTOM CONSTRUCTION 420.00 BF 1"irA
R' JIM'
GAR.aiWCARP0il T 112.00 SB'
CI'I
_
0FLAQUINTP,
FF
.J;t4.F0�r"3'
Ymnamm) Con or cormfbm.ox
P "ST` YEE sum- /uA.t Y
CO NSTRUCTKYN FEEL 101-000-41%,-000 U)1:00
PLAN CHECK FW 101-000439-31€3 $ A.82
Wk" 1TAii ICAIL I.F, 101-000A.21-000 W.S0
PIL- ECTRICIA.L YFE 101-00f"20-000 $31.14
;aulilNY}TTWO ".F, 101 -OW -419-000 $42,00
STIZONO A40'i'1014 FEE RESIU 101.000-241-000 $3.11
t il2lliii Nu 2 � 101-000-423-000
81JR41'(31-VAL C ONST9=t%SC'9'It7A1'.AND PLAO CHECK
10020, a
LF23 PRR-PATD► FURS
T €2'iAL FEMME I" SS DUR POW
$7M.81
RECEIPT
DATE_ ////
��, .n
B'(
J _.oa3-Do�
DAT FINALED
I CTOR
(/
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
F.A.U.
Framing
Compressor
Insulation
p2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3 py
Drywall - Int. Lath
S ?4,D -z-
/7
Final
Final
POOLS - SPAS
BLOCKWALL
APPROV LS
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
Electric Final
Waste Lines
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
Final
Utility Notice (Perm)
W
, ;+r . e t„ A,r . � : { � r a. ^ •i , f � m j{n '"t �i � �.+n. r n . � ��:. ,.� i
c51
Desert':Sand&Vfiified School District. ,
47 950;D}une Palms Road
Notice:MI La umta, CA92253
Q.
Document Cannot BeDuplicated , 760-7x718515 ti
CERTIFICATE' jKCOMPLIANCE`'
Date 3/13/02 APN# 775-241-014
No. .23043: Jurisdiction La MQu nta
ownerNameDonald Eliason s' Permit # 0203-037
,#
{ No. 55830 St eet Pinehurst,., F �. Log#
City La Q.uinta ' Zip 92253`" ±Study Area
Tract # Lot # , ' Square Footage ` 430
Type ofDevelopment Re`sidenttal'Addition '' +.. < `�.• No. of Units '1
CommentsGA WEST t,,R`es'idential Addition of`den at 430 sq.'ft.
At the present tune;•. the Desert.'Sands Unified School District does'not*'collect` fees on., garages/carports, covered
patios/walkways; residential additions urider 500 square"feed'"detached accessoryr,tructure•s or replacement mobilehomes. Jt
' has been determined`the above-named owner is exempt from paying scfiool. fees atthis time due to the following reason:.
' ,• 111.E -
° 1 Residential Addition, 500 �Sql Feet-4or L_ a S,
EXEMPT F ,.
This certifies that school facility fees imposed pursuantto Government Code 53080 in the amount of
t
0:00 'X 430 or $ 0:00 > the property listed above and that.building
^ t ,
pernufs and/or'Certificates'of Occupancy for this square'footage rn,this proposed project may now be issued
Fees Paid:By Exempt' - Bill Howard , Telephone 760/346-5300' .
Name on the, cliecli
By Dr. Doris Wilson 1
Superintendent-
Fee collected /exempted by :.Crystal Scott. Exempt. $0.00
„Check Nb."'-
Signature
NOTICE: Pursuant to Assembly.Bill 3081' (CHAP 549, STATS.f1996) this will serve to notify.y;u that the. roval period in which you may protest the fees or other payment identified
above will begin tofiun from the; date on which the budding or:installation-permit for this.projebt issssued •or on which they are.paid to the District(s) or to another public entity authorized to
r collect them on the; District('s)(s) behalf; whichever 1s earlier.'
Copector: Attach a copy of county or city plaq,check ap,phcation form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy `i Applicant/Receipt ' Copy '•Accounting
• ... .rf •.. .. �"1'.. , .. ... ll: '."S' I ... _. x i .k:'. .. - - R• .. h� -. f:. 4'. .. 1- ., .. N
JUN -10-2002 08:48 PM
INSTALLK
rY
reit
CERTIFICATE
DUCT LEAKAGE AND DESIGN
P. 02
CF -6R
UGT Lee^ pr, 1%W"WW 4 w..
Pressurization Teat Reaulq (CM `WS PA) Test.Lal �e(CFM). J.�.
If Fan Flow Is Calculated at 400 chatm u number: of tom, Of 2 t 7 x°Heating Capacity
hrThousands of StWhrreatar aticulateQvalue.here �"��
If fan now it Measured! .mgff. meed value here'
Loatcaae Fraction • Test Leakaget(Meuure0 bf ClIculkced Fan'Plow)
Pus Ifileattage ftacdoA S 0-0fWT ❑
Pass Fail
❑ For AF,it0SOL TYlZ SEALANTS -ONLY - The following dlaPmdc tesdng was Computed:
Duct Pen PreaeurirAdoA at fougb4s meawred leakage (CPM)
CHZCX AMR b1MSMNG WALU
❑ Yes C1 No Q Pressure pan test or House prewuritatloe mat
❑ Yet " ❑ No `Visual`Inipoodon of Duet CoNteetloAs ❑ ❑
Past Fail
91 THERMOSTATIC EXPANSION VALVK lam)
eyes E3 No Thecmosratie lbxpondon Valve (or Cotfi mosion.8 , oved
__ .. _ _ �:,: t�v�ivalent}ia°instilled>and-Aeceao to pr+ovlde0 to%inspection - - - ❑
Yee b a pass us Fail
D .DUCT DESIGN
! ❑ Yes ONO ACOA Me—M-1- D; DWp:okuh*M bave;been completed
Duet,Design is on the puns and-ductiiuullation snatches
plan,,
2. D Yes ❑ No TXV b Installed of Fan flow lies been veritled If no TXV. , f
verltied fan flow inatches desip Atom -CF -1 R.
Measured Fan Flow •_
Q ❑
Yea for both 1 and 1 is a Pass Pass . Fan
❑ I, the undersigned, veriij► that the above diapmtie test mulm std the work I performed associated with the tests) is in
confornmu wtih the:raquirenrems, for eanplianee credit. [Titie builds-14MU-ptovide the HERS provider a copy of the CF-dR
s4 and by the builder ernployees of sub -contractors eartiljriitg flint diagnostic tatting and installation meet the requirements for
compliance credit.)
Tess Sigaature,.Dete Lutalllineontrwctor (Co. Norm) aR
Perfmmd Oeneral Contractor (Co. Name)
COPY TO: Building Deparmrent
HRIS Provider (if applluble)
Building owner at: occupancy
JUN -10-2002 06:40 PM
Plan"Number
Sample Group Number
Semple House Number
Firm: pL, Mfats erovlder. ,¢-�S�AL
Street Address: CitylState/zip: _��
Copies to: Builder, HERS Provlder '
WFQS RATE .CO PLIAN E-6TATEMENT_
The house was: pTested Approved ss:pert of sample testing, but was not tested
As the HERS rotor p ovldlnp diagnostic testing and yield verification, I certify that the houses Identified on this form
co
m ly with the`diagnostic Cested compliance, r"'ulrements'�es'checked'on this form.
Distribution system Is fully'ducted (I.e., does,not use bullding`cevlties.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 adheaiva ducctape'to seal'leaks4tduct:connectlons. .
P.03
'MINIMUM REQUIREMENTS FOR DUCT LEAKAGE,REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing'Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (C.FM C 25 Pa) values
Test Leakage Flow'In CFM9
If fen 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 LeakagelFen Flow)
Check. Box for Paes or F611(Pass=6% or`less) ❑
ress IFall
eTHERMOSTATIC EXPANSION.VALVE (TXV) or Commission apt roved equivalent
CfY. [3No Thermostatic Expansion Valve (or Co mmission.epptoved
equivalent)'Is installed and Access Is provided,for. inspection ❑
-Yes Isspass Pass Fall
❑ MINIMUM RECUIREMENTS FOR.DUCT DESIGN COMPLIANCE;CREDIT
1. q Yes O No ACCA Manuel D Design requirements have .. met
(reter his verified thef•actual Uietaitatlon matches values in
C A R and design on pian.
2. 0 Yes 17 No TXV is Installed or Fen flow has been verified. If no TXV, / V
verlfled`fan flow matches de'slgn from CFOR.
Measured Fan Flow =
0 O
Yes for both 1 and 2 18 a Pass Pass Fail