0306-157 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing withrSection 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class _ Exp. Date
78M,34 M( �� Lt�i3 6Z C
.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).
( ) 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'.:1r1'r',1s`t Policy No.
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
3 subject to the workers' compensation provisions -6f Section 3700 of the Labor
Code; I shall forthwith comply with those,p�ovisions.
•,'
Rate: % fir:, � Applicant
Warning: Failure to secure-•Work`e'rs=Comps sation 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 1epresentatiives-of this City to enter upon
.4 the above-mentioned property,fo/r insspection,,purposes.
f
Signature (Owner/Agent) r+'r± :tom ,= Date> -vk, .
BUILDING PERMIT PERMIT#
DATE VALUATION LOT ("K , 45 t TRACT
�y
JOB SITEAPN
ADDRESS 77„ ;
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
i
Compressor
Insulation
— U
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 L
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
�G
Appliances
Final
Final
Utility Notice, (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service:
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final p4z ;2
Utility Notice (Perm)
COMMENTS:
Certificate of Occupancy
Tjbt 4 4 4"
Building & 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.
Use classification: SFD
Occupancy Group: R3
BUILDING ADDRESS: 77-705 CALLE CHILLON
Type of Construction: VN
Owner of Building: POWER FINANCE ASSOC. INC
Building Official
Building Permit No.: 0306-157
Land Use Zone: RC
Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 1-13-04
POST IN A CONSPICUOUS PLACE
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 1,514 S.F. or $3,239.96 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/Valley Independent Bank - Mike Brockman Check No. 287259
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sha cGilvrey $3,239.96 —5-55
Payment Recd Over/Under
Signatu e
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
JAN -12-2004 07:11 AM
TIFICATE OF FIELD VEWFI
IS
Date/ G
Builder Name
Plan Number
Semple Group Number
Sample House Number
Firm:HERS Provider: �G.� ey d6� I
Ocu n u
Street Address: 7�'6�0 ,�i�.✓cZ�i�Yv �l G� City/StatelZlp: L�!
Copies to: Builder, HERS Provider
HERS RATER COM.P.LIANCE STMEMgNT
The house was:Ell Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verlficatlon, I certify that the houses identified on* this form
comply with the diagnostic tested compliance requirements as checked on this form. I
Coyly
system is fully ducted (I.e., does not use building cavities as plenums or platform returns in lieu
of ducts)
Where cloth backed, rubber adhesive duct tape Is installed, mastic and drawbands are used in combination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections. ;
P-07
I CF -4R
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM
If tan 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 Leakage/Fan Flow) =, �•
Check Box for Pass or Fail (Pass=6% or less) []
►'es,s Fail
THERMOSTATIC EXPANSION VALVE TXV or Commission apEroved equivalent
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access Is provided for Inspection❑
Yes Is a pass
❑
ass Fail
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. O Yes 13 No ACCA Manuel D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1R and design on plan,
2. O Yes O 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 =
(� O
Yes for both t and 2 is a Pass
Pass Fall