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LICENSED CONTRACTOR DECLARATION
I herby 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
Date Signature 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).
o( ) I, as owner of the property, am exclusively contracting with licensed
tractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am,, exempt under Section B&P.C. for this reason
'3
Date 1�,' .r l �+ Signature of Owner -! ,. �� ,_ `\, .
K ..r .., .. ,_ x::. ___-
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 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 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date''„IoVO & Applicant `� . •-. - -” .
Warning: Failure to secure Workers' Compensation overage 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.
Signature (Owner/Agent•)•- -�� '�` Dated '
t
BUILDING PERMIT PERMIT# CONTROL#
DATE VALUATION '�� LOT TRACT
7678
,��•��'
JOB SITE
ADDRESS 78.4401�..,t��Y.f�KS CIRC�lI?. APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
KURTF & LF]KA S SCj: OPPF OWNFIZ R s1JUL"N .t.
'79-640 CARNES CCR
[AQ1J11Vf1X CA 02253
USE OF PERMIT
itt?tbif: D
CONVERT 31W i AY OF GARKOE, iU :.W S.F. HOW; 0171"PA.,
BONUS ROOM
2&11.00 it
1;S, !LA1AT r)1b cos's" OPT COINSTRU4:,TION ,
PLANC1,4 KXkMH'�G.tdhi(?-�3�-a:l� �c�.Vit►
N1.0T!r STV FPT. - RE Sit)
1101-000-4119,W
sqn tiff
101-000-421
SZ1.40
iU!-000-420-M
$22.(N)
101 -0t'9) -24J -(X)0
9_69
eL
OGbLESS PLI,434�1%ID
TOTALTVRIMIT PCES 00C NOW
RECEIPT DATE By fi \ I DATE FINALED IINSPECTOR
6,940.410
Moo
SY9x.69
A..
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 pl��
''
F.A.U.
Framing ,(o_
Compressor
Insulation
.. / 2 —
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath—
Drywall - Int. Lath
--ls —
Final
Final — —
BLOCKWALL APPROVALS
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
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
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:
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 225
(760) 777-7 2
FAX: (7 7 -
O*NER'S SIGNATURE/DATE
7% uo e,��5 -I-,o
PROPERTY ADDRESS
99q-i13l
PERMIT NUMBER(s)
4
1
9
_7.2 CO.NIPL1ANCE ANALYSIS OF
AN ADDITION ALONE
Anv addinon — that is, the sum of all new
,:ondttionea soaces and associated new extenor
walls. ceilings. and tloors within the building —
:nav nc snown co meet the cncr1:V Mucci, as .a
,�eparaic cnan-. flus pmccaurc docs not involve
ttie exntine structure. except when c::uc;ulsung the
water ticauna cncrcy use for any addition in which
the total numhcr of water heaters to the bucldinc
increases. Thc anaivsis may he periormcd using
either a special prescnpttve package ac:cordi is to
the size of the addition or with the point svgcm or
any approved computer pcnormance me:noa. ,
Table 7-1: Prescriptive C01, 1pli2nce of Additions -
Summary of Section 152(a)1 Re uirements of the Standards
COMPONENT
100 ft`
I(N)-499 ft-
500-999 ft-
2 1000 ft`
Insulation
'Ceiling
R-19
Packager
Package
Packagc
Wall`P
R-13
R-13
R-13
Packagc
Floor
R-13
Packacc
Package
Packacc
Fenestratign
U -Value
0.75 ,
0.75
Package
Package
of CFA
<_ 50 ft`.
Pkg + Removedl
Pkg + Removed
Packagc
�. Shading
Na
Package
Package
Package .
Thermai Mass
r n/a
Package
Package
Padfacc .
Space Heating
Mandatorvs
Package
Package
Packagc
& Cooling
(No electric )6
(No clecinc t
(No clectnc )
(No clectnc)
Water Heating -
No Increase &
No Change
Na
Na
Na
n/a
Repiacement:
No Increase-
Standard
Standard
Standard
Standard
Increase
-kuowcd
Allowed
Allowcd
Allowed
w/Calculations
w/Calculation
w/Calculation
w/Calculation
1. Meet the component prescnpuve requirement for Package D for slab -on -grade construcuon or
Package E for raised floor construction (see Chapter 3), l
'_. "Heavy" and "Light Mass" mass walls may meet the Package D or E requirements for mass wall
insulation instead of R-13 (see Chapter 3).
3. For compliance of addicions,and alterations only, dual glazed "greenhouse' windows and skvliahts
may be assumed to meet this requirement.
4. The Package D or E fenestration area plus the area of any glazing removed because of the addition.
S. All mandatory measures for HV AC systems must be met t see Chapter 2).
6. No eiectnc resistance space healing may be installed.
7. A standard water heating system is explained in Section 6.6.
S. If the total number of water heaters increases in the residence, then the entire existing plus addition
system must meet the water heating energy budget (see Chapter 6): Table 3-; lists water heating
,y% -.m combinations which have been pre -calculated to comply with the water heating budget.
7-4 Revised January 1992 Residential Manual
Certificate of Compliance: Residential
-78Ctfo CP-ONEs ct 2
Project Title
(Page 2 of 2) CF -1 R
HVAC SYSTEMS
Note: input hyaronic or cort+otneo hydromc data under Water Heataig Systems, except Desgn Heating Load.
Distribution
Heating Equipment Minimum Type and Duct or
Type (furnace, heat Efficiency Location Piping Thermostat
puumo. etc.) (AFUE/HSPF) (ductwattic. etc.) •R -Value Type
F
Cooling Equipment Minimum Duct
Type (air conditioner. Efficiency Location Duct Thermostat Configuration
heat puma. evao. cooling) (SEER) (attic. etc.) R -Value Type (sold or oackage)
WATER HEATING SYSTEMS
Energy, External
Rated' Tank Factor or Tank .
Water Heater Distribution Number Input (kW Capacity Recovery Standby' Insulation
Type Type in System or Btu/hr) (oallons) Efficiency• Loss (%) R -Value
16XeSr74e'1144fr�j
1. For snail gas storage (rated input S 75.000 Bd/hr), eleetrie reslstaneo and hest pwnp wet« hasters. list Energy Factor.
For large gee storage water hastens grated input a 75.000 Bturtu), list Rated Input. Recovery Efficiency and Standby Loa.
For Instantaneous gas water hestans, list Rated input and Recovery Efficiency.
SPECIAL FEATURESIREMARKS (Add extra sheets it necessary)
COMPLIANCE STATEMENT
This cemicaie of comphance lists the building features anti pertonmmu specifications needed to com" vmo Title 24. Parts t and 6, of
the Califorma Code of Regulations. and Ihe.admtrustraove regulations to implement them. This certificate has been signed by the
individual with overall design resaonsibility. When ous certificate of compilanoo is submitted for a single building plan to be built in multi0e
orientations. any shading feature that is vaned is Indicated in the Special FeatureslRemarks section.
Designer or Owner (per Business • Professions code)
Nane: Ku a.T- s c-�OPPL
TidefFinn: OwNe e.
Address: c t e_
L4 QLxL J*rA CGS% g Z2S 3
Telephoned 76 31.0 -531
U tr ,
(sViawre)' v (dam)
Entorcement Agency
Name:
Title:
Agency:
Telephone:.
(Swialunw=tarrip) • (dw)
rlevtoc�,t;,s...r • ;t1q
Documentation Author
Nam.: SA-,, F.
TitlWFin:
1d&sta-
.-rtiricate of Compliance: Residential
(Pace I OT 22) CF -1 R
iect nue Date
ojeet Address Building -Permit a
KLk --+ Sc, P� 76b Plan Check Date
ocumentation Author Telephone
Field Check i Date
ampliance Method (Package. Point System or Computer► Climate Zone Enforcement Agency use Only
1ENERAL INFORMATION
.otal Conditioned Floor Area:
'uilding Type:
:heck one or more)
:vont Orientation: (go
vumber of Dwelling Units:
-loor Construction Type:
2 oy 42
Single Family .Addition
Mufti -Family Existing -Plus -Addition
North/ East I Rrees
st i All Orientations
(Input orientation d circleone.)
t5 a_W Raised Floor (circle one or both)
3UILDING SHELL INSULATION
Construction
:;omponent Insulation Assembly LocatiorvComments
type R -Value U -Value (attic. to garage. typical, etc.)
Wall ..............
Wail .............. 13 7'vPra4-c_ 6,Kz*gro2 wa tt_
Root ............. 38
Root .............
Floor.........'..'
Floor.............
Slab Edge ....
FENESTRATION Shading Oevices
Fenestration Area Fenestration Interior Exterior Overhang Framing Type
Orientation (sf) U -Value (roller blind, etc.) (shadescreen, etc.) lves/no) (metaYwomwinyl)
Front..... (5) _.2q n . 7 S' recLjf--z RUAJAC-
Front..... ( )
Left....... ( )
Left....... ( )
Rear...'.. ( )
Rear ..... (. )
Right..... ( )
Right..... ( )
Skylight .......
Skylight.......
THERMAL MASS
Type/Covering Area Thickness
(slab/exoosed, tile. etc.) (sf) (inches) LocatiorVDescription (kitchen, batn, etc.)
40
RqVisad January 1002,
..
.-N . .
Table 3-Z15: Prescriptive Packages for Climate Zone 15
Package Package Package Package Package
Component A B C D E
BUILDING ENVELOPE
Insulation Minimums:
Ceiling R-30 R-38 R-49 R-38 R-38
Wall r R-19 R-19 R-29 ' R-21 R-21
..Heavy.. Wall (R-5.5) (R-4.5) K/A (R-4.76) (R-4.76)
"Light Mass" Wall (R-7.01 (R-6.01 N/A N/A N/A
Slab Floor Perimeter R-7 R-7 R-7 NR NR2
Raised Floor R-19 R-19 R-21 R-193 R_ 19
FENESTRATION
Maximum U- Value 0.65 0.65 0.40 0.65 0.65
Maximum Total Area NR 16% 16% 16% 16%
Maximum Total Nonsouth Facing Area 9.6% NR NR NR :YR
Mitumum South Facing Area 6.4% NR NR NR NR
SHADING COEFFICIENT"
South Facing Glazing 0.15 0.15 0.40 0.40 . 0.40
West Facing Glazing 0.15 0.15 0.40 -0.40 0.40
East Facing Glazing NR NR 0.40 0.40 0.40
North Facing Glazing NR NR 0.66 0.66- 0.66
THERMAL MASSS REQ NR REQ 20% 5%.
INM- TRATION CONTROL
Continuous Barrier NR REQ NR NR NR
Air -to -Air Heat Exchanger NR REQ NR NR NR
SPACE HEATING SYSTEM6
Electric Resitance Allowed NO NO YES NO NO
If Gas. AFUE= 78% 78% 78% 78% 78%
If Heat Pump.
Split System HSPFB = 6.8 6.8 6.8 6.8 6.8.,
Single Package System HSPF = 6.6 6.6 6.6 6.6 6.6
SPACE COOLING SYSTEM
If Split System A/C. SEER = 10.0 10.0 10.0 - 10.0 10.0
If Single Package A/C. SEERS = 9.7 9.7 9.7 9.7 9.7
DOMESTIC WATER HEATING TYPE
System must meet budget. Meets Meets Meets! O Meets Meets
see §151(b)and 151(f)(8) Budget Budget Budget Budget Budget
LEGEND: NR = Not Requurd: N/A = Not Applicable: REQ = Requited
See notes following Table 3-Z16.
Prescriptive PaCkag@S Revised January 1992 3"35
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