0306-041 (SFD)LICENSED CONTRACTOR DECLARATION
til 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
r:
Datef— Signature of Contractoy��„�, «s,
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:
�E•:Carrier VA.`ZPolicy No. g- dli"?:18a:1
(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 tolthe workers' compensation"provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions!
Date: Applicant-
Warning:
pplicant 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/fbrinspection purposes.
2
.-Signature (Owner/Agent)' J. �f/ s•'''?- %' Date
V
-. -49UILDING PERMIT PERM&T#
(1:9 L)a t
DATE `- VALUATION LOT TRACT
TWX 66
JOB SITE .�
APN
ADDRESS .1MA V
OWNER
CONTRACTOR/DESIGNER/EN &NEER
11, fh .a R 11
P:c. W?K134
41-760 E' �0
'�:r',
LA QpyM :pD 922J))
.d•��t g y� /�S
BIW, iI)�qi�.1l9
(760408.75218 C 1h 37'Z4
USE OF PERMIT i
OWNC A.F.M.-C Y3?�i r':14 C3
WIS &V, 313ira,°FS;KMIT P. O&) N-Cl71N 0.0 POOL OR
TRACT f:O:rlS'fRUt;3' YW t,•BSS ;CfA
0Al2AGEMARPOU 520130 039
:M ax ,T) co 'r cur c01,W�"%dV_-MV_X
�T'�w:�:S,`a'0
PLAN CHECK k*wE tg g48&.�Et
FE49 WOW l as l-CF00,4•59 ,, , 8 .:620100 '
mc-11ANIC&L.117"P. 1,01-0,0` L 42.1 -04t0
S' L1;CM1[v'A,..c .E ty
t?f.=ixmblIIo11fu* i`1 -000-419J 00
RAMNOYZE, 1014= 42 4M• 33,13Fi
DX.'V'MOPER Ml ACT Mss
am-- Cid: , 6ONS :li��O � ION''AUM 1"As .4I' CIY4,
�,3 i q,
I EVS FF11.11AID T7``X(i
,861.
NW0X"O
1. FEDug, NOW
JUL 0 2 2003
CITY OF LA QUIP1TA
DEPT
RECEIPT
DATE
BY` r' /'
DAT INALED
INSP
INSPECTION RECORD
411
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
7- CJT
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
vCombustion
Air
Roof Deck
Exhaust Fans
OX to Wrap
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
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 Unes
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
70 77-70--Z
Appliances
-
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbitures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power Q
t
Final
Utility Notice (Perm) S
COMMENTS:
{:
-
CERTIFICATE OF COMPLIANCE
"Desert Sands Unified. School District'
- 47950 Dune Palrris•Road`
q Q BERMUDA DUNES
Date ' 7/1/03 La Quanta CA 92253 RANCHOMIRAGE (� '
- INDIAN WELLS
24644 (760) 771-8515 ti_
_ PALM DESERT
No. �'. ��,� LAQUINTA '
Owner Thomas Buffin: APN # l ' 773-083=023 • T
Address' " P. O. Box 134 r •- Jurisdiction La Quinta #
r City' La Quinta • Zip,92253 • Permit # 0306-041
Tract # BL.K 66 '-
, Study Area, ,
Type - Single Family Residence No. of Units
Lot # ,No. , ' _ Street ' S.F. Lot # No.. Street S.F.
Unit 1 11 51465 Avenida Vallejo - 1.408 Unit 6
Unit 2 t '_ "' Unit 7
Unita Unit 81. ,
Unit 4 ' Unit 9
Unit s - ✓Unit 10 . F
r.
Comments
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: "
? �;I r
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 • $2.14X1,408 s.0, or $3,013.12 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 CCNalley Independent Bank-David'Addirigton check No. ;287296 ;
Name on the check Telephone 760/408.7528" r
Funding Residential
By 'Dr. Doris Wilson
Superintendent -
Zi
" Fee collected /exempted Y. Sharon McGilvrey $3,013121 $o.00
Payment Recd, OvedUnder
Signature
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
t 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 w E
Embossed .Original -'Building Department/Applicant ✓ Copy - Applicant/Receipt Copy 7 Accounting
DEC -11-2003 07:23 AM $� P.01
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING ] CF -41A
Prat ct Tale Date -
PrO'�ttddress V,, - .�" Builder Name
Builder Coni ct Telephone Plan Number
/N U .5
HERI Rater Telephone Sample Group Number
rtrfying Signature "Dake Sample House Number =.
-r'. w •.I ,. ter- � , �f . ':r .
Firm: HERS Provider. -J .C.,_ 1S5oG�1
Street Aadr"ess: 7 6�0 i ��� 0✓� CYG -ems Clty/state/Zlp; Z�l O /o�- Gdl' , ✓:
— —
.Copies to-, Builder, HERS Provider
HERS RAJEB COMP61ANCE STATEMENT i
The house,was: Tested i ❑ Approved as part of sample testing, but was not tested
As the HERS rater roviding diagnostic testing and field verification, I certify that the houses identified on this form
co�?y wilcom y 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)
Ld Where cloth backed; rubber adhesive duct face Is Installed; mastic and drawbands am used imcnr ibinati�n }
with cloth backed, rubber, adhesive duct tape to seal leaks at duct connections.
4,MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6%. Duct Leakage) }
R. Measured
V4�f rIC.1''aUr14titIVII 1 U4 RpSUl'ta (Co FFM Q 255 P ) t values
f
Test Leakage Flow In CFM
if fan flow is'calculated as 400cfm/ton x number of tons enter..
calculated value here
If fan'flow is measured enter measured valva hPrP `
Leakage Percentage (100 x Test Leakage/Fan Flew)
Gheck Box for Pass or Pail (Pass=5% or less) ❑
c ; f Pass Fai!
t.
I nCKrOVO I rqr 14 tArAI ZIUN VAJ vt ' I AV)• or Corn -mission aperovea a uivalent N..
Yji
es + ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and. Access is provided for Inspection ❑
Yes is a pass, r Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT I
1. 0 Yes Q No --ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values In
CF -1R and design on plan;' Al) u! ►
2. 0 Yes 0 No . TXV is Installed or Fan flow has been verified. If no TXV, o�
verified fan flow matches design from,CF-1 R.
Measured Fan Flow = I1
Yes for both 1 and 2 is a Pass Pass Fal
an
Buildin.g & Safety Department
This Certificate is issued pursuant,to the requirements of Section 109 of the -California Building .
Code, F, 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.
BUILDING ADDRESS -,51-465 AVENIDA VALLEJO