0106-378 (SFD)LICENSED CONTRACTOR DECLARATION
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
71,2 43 l3 t,< ..' ��C!5'31I'2(
Date �� `r -- Signature`of,06At ctor
----- ._ -.,-� -- OWNER=BU LI DER DECLARATION
I hereby affirm under penalty of perjury that I am a,4empt 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. No.
IMPUP -
(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 provision s"\/
bate. �, . APPlicanf-% �� 9 t,'
WarniH—g`-Faiiureto secure! Woor`kers"C'ompensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,;,
for a permit subject to the conditions and restrictions set forth on his
application. < r-
177
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this •application and state that the above information is!
correct. I agree to comply with all City, and State laws relating to the building'
^
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fo�,Jnspection purposes:
Signature (Owner/Agent)`_'=<. 1'_F° Date / s� S
BUILDINGPERMIT PERMT#
DATE VALUATION LOT QE��ii�- %E} TRACT /
6� G py 1 t e +
�.7rJ nS.:Yu ba.•L �D.7.Sfb!. 1 cirl.l6i� L � dG. �t..Y �.
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN INEER
1.'EGArY Int r i L-
1 402 MAC'",
41-% 50 ADAW fiYl.tX1 Kf iV426
U;MTA ,(t,1+(A CA �2 705
LA, QUMA CA 92253
('760)554.7820 CMS$' 02063 ,
USE OF PERMIT
2.1HOLf? FAWLY DW17l.1WCI
i
SFD - 11:f��:ili IT IDOES NOT R1+ffvLaJ.DE OLOCli't1Jfil.:f,,S, POOL„ QR DR-IVzW.AY
.AP45RcyAt'HId,MWIH MASTER MAtAU 3
T' Al: T C00STRUC'.' ION 1„' .00 SF
F ORC- 1'I1C{.�1: IO 4 4.00 SA'
f;AMt..$ EJC'I'tA1OP-.T 469.00 SF
CONEY UCTION ME 301-000-416-000 $660,50
PL -p � OI-FF>� K FP' 101-000-.439-318 X 32.20
FFX !?TMM 101-000-439-318 �2SO,OA
W41HA7v1C AL PER 101-000-421-000 �6Lt.0if
X1;E+:`.7! RWA1a FRE 101-000420-000
f=�,t1t aaz1 fir 101-000-41.9-000 �D3�.o0
S1! OW0I�OTION F - RES1D 1it1-000-2�7-000 St.0,t1$
r
GFfAPYHO r.ZE` 101-000-423-000 $afJ.t�O
U&.�b'ELOP1^! R IMPACT FSS ;. ffii,401 Of!
PR2613E;.PLAN 101-Qi10 4.41-3<i5 $1®O oa
.,
kTit1M°YOW AND A.”{ MY& 7%R
'.04
LEN P REF -PAW FLIM
-wuo
2 5
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'IrdWp, naw tr'y'ms`s Dognow
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H1, Aire 1i Li'I I
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs I
Underground Ducts
Forms & Footings j c s-
Slab Grade I
61 ^4
Ducts
Return Air
Steel )
Combustion Air
Roof Deck J
O!
Exhaust Fans
O.K. to Wrap 1
_
F.A.U.
Framing I
Compressor
Insulation 1
Vents
Fireplace P.L. 7
Grills
Fireplace T.O. )
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall 1
Exterior Lath
Drywall - Int. Lath
9J/Z�
/r
1
Final
oz .
Final
POOLS
- SPAS
BLOCKWALL
APPROVALS
sceN
Set Backs 1
Electric Bond
Footings
Main Drain
Bond Beam J
Approval to Cover
1
Equipment Location
I
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROYALS
Waste Lines �cl ��
Water Piping tPlumbing
Gas Test
Electric Final
Heater Final
Final
Plumbing Top Out 1
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral I
Pool Cover
Sewer Connection 1
Encapsulation
Gas Piping i
Gas Test ]
2
Appliances 1
1
Final
COMMENTS:
Final
Utility Notice (Gas) i
ELECTRICAL APPROVALS
Temp. Power Pole ] �� 3
Underground Conduit
Rough Wiring
Low Voltage Wiring 1
Fixtures
Main Service i
Sub Panels i
Exterior Receptacles
G.F.I. 3
Smoke Detectors
Temp. Use of Power
I
Final O
Utility Notice (Perm)1 _ —72 pZ
b�D
Building
Address 1
4uulctcv 3
f P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Owner
Mailing 7
Address / % C,)2
City Zip Tel.
�t 'N I A A -A) i+ 1 G" 0
Contractor / eb f,� ^ / eS
Address (� f
Cityy 71 Zi -+,T State Lic. & Classif. � r .�#
r
Arch., Engr., i t ! wr
Designer�I'1�
Address Tel
7; r
'1 �f— � �
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, 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 thathe,is exempt therefrom, and the basis
for thealleged exemption. Any violation o/ Section 7031.5 by 'any appl' t tort a permit
subjects the applicant to a civil penalty of not more than live hundred dollars ($500). \
1'! 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, 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.)
7 1 am exempt under Sec. S. & 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
fl Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1hereby 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 if work thereunder is suspended for 180 days.
I certify that Ihave read this application and state that the above information Is correct.
I agree to comply with all city and county ordinances and state 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
JILDING: TYPE'CONST. OCC. GRP.
P. Number
lgal Description Z ”
oject Description
of
Sq. Ft. No. No. Dw. f
Size / Stories Units
Newx v Add ❑ Alter ❑ Repair ❑ Demolition ❑
I
imated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
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:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert: Sands Vnified. School District
47=950 Dune Pa1msAoad'
Notice: La .Quinti, CA 92253
Document' Cannot Be Duplicated' .760'771-.8515
`CERTIFICATE OF'COIVIPLIANCE
Date 7/25/01APN# ."646=313-022
No. 22309 Jurisdiction. La'Quinti•
Owner Na>,neWilliam Doherty 3. tr PeirmiY#
No. 78-723 Street Saguaro Drive, Log`# .
City La Quints Zip 92253 Study Area
Tract # Lot # Squark&Mage 1788
Type of Development Single Family Residence No. of Units- 1
Comments `
At the pmeser
patios/walkways, residential additions under 500 square feet fdetached accessory structures or replacement mobilehomes. It
gliasbeen determined the above-named owner is exempt from paying school fee"s.''at tlus.tiine:due to the following reason:
EXEMPTION=NOT APPLICABLE
This certifies that school facility -fees imposed puisuant;to , Government Code 53080, in the amount of
2.05 X 1 jo or $ 3,665:40 the propertylisted above`and that building
permits and/or;TCertificates of Occupanc"yfor this square footage in this proposed ect:may now be issued
Fees Paid By .cc/1 st Bank/Sharon Bills'- Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
,Fee collected /exempted by Juanita:
... I
F4
jo �M
At
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7145478909; Jun-"20-Oi jo:22AV,", page 213
DEID'10 REAL PROPERTY
We, HOWARD SMITH AND -JANET W. iSMl-jjj,!a3 CO-(ivardi :
ans of the estate Of
DOUGLAS ANDREW .SMITli, a jWAOr, Pur -quant to the order Of the-Suptrior Court of the State
C9,11fOrni4, for the County of Los Angeles, made in the i><tatter of the Guardianship Of DOUGLAS
ANDREW SMITH, a minor, on February 28; 2001, confirming sale . of reat property and directing
the execifftron—Of a conveyance, hereby grarif to WILLIAM j.
DOHERTY, Trustee of the William
44"Paw6'k T. Doherty, a married man as to
T Doherty Revociiblo Living Trust dated 1-30-97,� h
his sole and separqeproperty,
each as to a one half inte
resf'a$ tenants in common, all right, title,
interest and estate of the, said minor in i&e realproperty, to wit, a certain
parcel.of tinimproved
real
property in the City of La Quinfa, Count s; described as
'y of Riverside, State of CWiforni
follows:
,CLO�TT,122 OF IOESERYCLU '
13 -M -AN(
BOOK-22,PACit 53 ()F-.-MAps'-.'R.1-V-
-CALIFORNIA; SLJ,J3J-1E6T'-'T'0-FA1'9F,
CoMbIb6m, its E 7- - ` - " TRICTION.91" C(
TH
RECORDS OF RivERsiDL cc
Dated: Pcbn iar'y,28i1206I
NO. 1 A$
SHOWN BYMAP ON FILL IN
Ou�jtyv-Akokbk �*TA-4 :
1 I., . " � TE.'OF
1011TROF "AS' NTS, LIENS,
IXAY,� s
SAND"ALL
ALL bW7 - Mt' T, --F RECORD -IN
oU N S Q
%LIFORNIM,
L/
--
'0-
uarvan
Nam- fflft5gm 00-0-D
Date& Fe6ruary J8,2001
JET' Co -Guardian
STATE Ol� CALI[,ORNIA
)ss.
COLJNTY OF, j.X),S,ANCjF
T,p
-'0xvFebrqary28 2001,before me;A-Not
MyPublic, personally appeared -Howard Smith,
(or proved to me on the basis of sattsfactory eh,6 O'NeAhe-person
Whoseis:subscribed to the within in§truancit•and
-
Woth h at 6 executed the
zed cja:*bity, ah0hat by his signature ori ihe inj Ment the pvtwn, or the
,MWUPon alf �o, wh, .,
'beh f . 1c if. -the person U -W, executedibe instrument..
WITNESS my,hwW and 61ricial seal.
s PQ
t
r • CF -.6R
�ISTALLATION CERTIFICATE
r78 -- 72 3 S9, s Y� - 7.Permit Number
Site Address y'
DUCT LEAKAGE AND,DESIGN'DIAGN'OSTICS
❑ DUCT LEAKAGE.REDUCTIOk`
Pressurization Test Results (CFM @ 25 PA}. �J
Test'Laeakage'(CFM)
Fan, Flow
If Fan Flow is Calculated as 400 cf n/ton x numbei,of,tons,`or as 21.7 x Heating Capacrty
�;in'Thousands of.Btuft enter calculated value here
If fan flow rs :measured, enter measured value>here
Leakage. Fraction Test Leakage/(Measured of:Calculated Fan Flow) 13Pass if leakage fraction <_ 0.06
Pass Fail
❑ For AEROSOL TYPE SE;ALANTSrONLY The following diagnostic`- testing was completed:
Duct Fan,Pressuriiation at rough'in measured leakage (CFM)..
CHECK AFTER FINISHING WALL:,
❑ Yes ❑ No ❑Pressure pan test or. House pressurization test /f ❑ ❑
No • ❑ VisuallI spection of Duct Connections Y Pass Fail
❑Yes ❑`
�3 .• n . N.
µ. a_ •
❑ THERMOSTATIC. EXPANSION VALVE (T)(V)
Fr. F,,r• a» ...
Yes 13 No Thermostatic Expansion Valve (or Commisston approved n ❑
equivalent) is installed and::'Access is provided for inspection pass Fail
Yes.is`a-pass
fl ❑ DUCT,DESIGN
❑ ;Yes ACCA:Manual D Design calculations have been completed,
I. ❑ No Duct Design is -on therplans;and duct installation matches
Plans.
.T—XV is anstalled or Fan flow._has been verified. If rio TXV,
2. ❑ Yes ❑ No ; .
venfiedrfan flow.matches design�from CF -1R.
Measured:Fan Flow ❑ ❑
zPass Fail
Yes for lioth:I and2 is a Pass
;..
I the .undersigned, verify that the above, diagnostic test ciated with the test(s) is in
results and the work I p the HERSssoovider a
copy of the CF -6R
❑ j-
conformance with the requirements for' comp credit [The builder sliall.proyide ti
r
• signed by the builder employees or sub -contractors cerhfjnrig that diagnostic testing!and�installation meet the requirements or
compliance: credit.]
a-S.Si7L�u
/ ; " Installing Subcontractor;.(Co. Name
atu) OR
Sign
osis - reDate
General Contractor (Co. Name)
Performed ,
COPY'TO: Building Department
HERS Provider•('if-applicable) • , '
Build'ing`Owner at O'ccupancy
January., 4,2001
Certificate of Occupancy
City of La'Qui-n'ta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building,. Code,
certifying that,* at =the 'time of issuance, this structure was. in compliance_ with the various.: ordinances
of the City regulating building construction 'or use: 'For the fol%win
g
BUILDING ADDRESS. 78-723 SAGUARO 'DRIVE
Use Classification: ,SINGLE FAMILY DWEL"-LINGBfdg. Permit No:: 0106-378
Occupancy Group: R-3; U-1 Type of Construction: VN Land Use:.Zone:. RM 174
Owner of Building: WILLIAM DOHERTY Address:
Building Official
City:
1.402_ PEACOCK HILL
SANTA.ANA .CA 92705
By: KIRK KIRKLAND
Date: 1-16-2002
POST IN A CONSPICUOUS PLACE
®ie