0209-164 (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
782324 :8 1 ITC P /3112(
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.3 Ines fFyPJ,o"ionals Code).
as�w. ner of�ttheC'op�ryf� am exclusively contracting with licensed
contractorsot constr,UC t he "ct (Sec. 7044, Business & Professionals
Code). I /�
I am exe t under ,40 B&P.C. for this reason
Date --;1A igatClr of Owner
WORKER'S COMPENSATION DECLARATION
I hereby afj' under p,pn ty,,��f erjury one of the following declarations:
() I hav� nil ma�n4ai `eficate of consent to self -insure for workers'
compensa�"6��rov� f Section 3700 of the Labor Code, for the
performance of the wort f ochis 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 9,1'AT.g yL t4L, Policy No. 3576357-0
(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 Yrovl30ns of Section 3700 of the Labor
Code, I shall f6ghwith comply with those prowls ons.
Dater Applicaht '`�- - r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his '
application.
1. Each person,upon whose behalf this application is made &each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees..
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of .issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to, enter upon
the -above mentioned property for ipecti • rS purposes.
Signature (Owner/Agent) �'�" r�""'-3' Date �1
BUILDING PERMIT PERMIT#�-1+i
DATE VALUATION LOT TRACT
JOB SITE �$
ADDRESSj.I
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PO BOX 134
775f 4-A C:01_.31TdRY MUZ DPWIx;, Sin�''.� 3' 4 �F
F.,1N01JiMA 'CA 92253
P'13t.M.IMEWC CA r4M1 a
('76q)408.34.95 01B S r
t
USE OF PERMIT
1421 S. F. S . PZYC:MIT 1l'ft"' ,'" T'I1NCLUtY lit' IZCX W611_% POOL. OR
F
I'M CONS' JC 4N �14�11.tkroll
Iri!`itiC•i?!dJse4,`.i`ItJ� :itr.0 g
.
rxatfC��.1fi 1'i'! SID. I� .
�i,'SKIMAM) COST Ole, CORSInRUCTAeIM
87,C?r�a'�.3.C3
1 ONOT.:�iiy qUATKARY
py..
CORM; s T°.1JCTION PEP, 101-000-4-18-000 , 5,585,60
PLAN CkIFLX i•'MS 101-000-439-319 1488,E
I+ ZCtx.r NICAI-
EL Cr T RICAL PEP, 141 -000-4i O.000 COM-`,
P;:FlA9 ME 101-000-419-000 $216.rVJA
W E; ,t7 "'40 ItiOTIAWN ArTPt�•', - RMSE02ii%: i v 1. 40MOb-241 ..010n W'.°.�• �`ai(e
CS1.9L'�4IV't11 ill, 101-000-4.23-000
DEV 1:+'%C'a1";E:t IMPACT '-QU?r
PRIM S PLA d $106.60
s
p LFII t`C3'1AL . 9 t'ZC��'C�C�tr�.A14D P1 �T�a t g���..1:1'1
�:�,F;'�i.01
p : ISS FXV*1? EVE,'
4250,00
NOV 2002 �� nmff 1 _c lmy, no
CITY TA
'
CE DEP
RECEIPT
DATE. (/l _ y
BY
DATE FIItJJALED j
INSPECTO��,ppp••• �•
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
—el L�2
Exhaust Fans
O.K. to Wrap
Q
F.A.U.
Framing
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
- ° 3
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
_.-
Electric Final
Waste Lines
- �G
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 U
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power fl
Final
Utility Notice (Perm)
a CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Date 10/8/02 La Quinta, CA 92253
No. 23708 (760) 771-8515
Owner La Quinta Partners
Address
City La Quinta Zip 92253
Tract #
Type. Single Family Residence
Lot #
Unit 1 '9
Unit 2
Unit 3
Unit 4
Unit 5
Comments
No. Street
51425 Calle Iloilo
S.F.
1421 Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
-��F�Sc�
Q BERMUDA DUNES O
Cn RANCHO MIRAGE
INDIAN WELLS
PALM DESERT ,y
LA OUINTA
ZP�QINOO y7
APN # 770-164-021
Jurisdiction La Quinta
Permit #
Study Area
No. of Units 1
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 1,421 S.F. or $3,040.94 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/1st Bank - Dick Scott Check No. 65439
Name on the check Telephone 760/408-3495
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Monica GuiUen $3,040.94 $o.00
Payment Recd Over/Under
Signature �Jilm) 111A Hi A I MIPIL.,
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
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
Hrolect Title
$ -Llai :4-1,9
PrA dress
XL
Budder Cont ct Telephone
�" fin /�7 o �✓1 '; SIV �7 d2 3
HERS,�Zater
Telephone
�s ifying Signature O
-16at le
Firm: J -C. d-,gSSOGI�%S
Street Address:
Copies to: Builder, HERS Provider
31'4110�
Da
Builder Name
Plan Number
Sample Group Number
CF -4R
Sample House Number
HERS Provider:
City/State/Zip: L y 0u Cad
HERS RATER COMPLIANCE STATEMENT
The house was: grTested ® Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form
comk with the diagnostic tested compliance requirements as checked on this form.
Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu
of ducts)
Zf'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.
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 / 3
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated here
value
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)
y ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
eyes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
❑
Yes is a pass
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
Pass Fail
. ❑ Yes ❑ No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1 R and design on plan.
2. ❑ Yes ❑ 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 =
Yes for both 1 and 2 is a Pass
❑ ❑
Pass Fail
Certificate of0ccupancy
City of LaQuinta
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 following:
BUILDING ADDRESS: 51-425 CALLE ILOILO
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction
Owner of Building: LA QUINTA PARTNERS
Building Official
VN
Bldg. Permit No.: 0209-164
Land Use Zone: RL
Address: P.O. BOX 134
City: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: MARCH 4. 2003
POST IN A CONSPICUOUS PLACE