0301-457 (SFD)_ � _ .. _ ..,tea. •.. - - _ _
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE' VALUATION LOT
Professionals Code, and my License is in full force and effect.„
License # Lic. Class Exp. Date '
JOB SITE
FJ829Ci 1 B 1 � ADDRESS _61() a E%3A r) Z
Signature of Contractor �° OWNER
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 '.A'TII pLTND Policy No. 229• NlM7.20
(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 provisiohs of Sectio.e3700,iof the Labor
Code I shall f,oQrthwith comply -with lhos�e provisions
'Date:11"J"1! � 3 Applica-ht,., 7
r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
Y
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize rep 1 sentativesyf?this City to enter upon
the above-mentioned property for sp ction pu &Ses°� ''1 __" .
.. � � -may
S gnature} (Owner/Agent) z+ '��� - Dater•` ✓
�_.i T""'
PERMIT #
-1$ ""57 TRACT
APN
CONTRACTOR / DESIGNER / ENGINEER
RM 23 U-2
52473AVF,1-WA.V'ALLEJ0 41-780HER TTAGY, DR
LF&QdMrA. %,A 922.53 F.9R.1A1J .-%D13'W3` cl9 201
�� yY C76OWS-7528 MLO 3724.
USE OF PERMIT j
SIN01-w- YdPlM1I Y
1.490 S.F. a"FD PERMIT DOS 140T YX'dfwIAIDE SLOCK -WApe, Pool, OR.
T; RXIM Y A4'i`1tO ACH, n
TRACT CONST MR,71 ON
PORCHIPATIO Ifk1.00 ??
0AR.AGUCARPt9Wf 440,00 3F
:1rymmy'l) Can CDS' c4wmC,`2" om
E'ER :T FIRE ;fit NAY
%`-011S`FWICTION RIE
101.00W-418.000
UK"
PLAN C1 FICK SEE
101-000'4.39-3 2 5
S501.111
FRIX, DEPOSIT
101-000-439-318
42SUO
MPC, HAM ICAL 's&B
11'1-0,00-421.0(10
� IWI
ELEC'1R AL -VEL
101,000420.000
5100.10
PLUMi INOFEE
10'1_000-11) 9-000
$124.00
STRONG MOTION ISE - RUID
101-000-241-000
49.x:
GRAXTRO Irl?It
101-000-423-000
$13.00
DEVELOPERAMP,ACT VEY,
U,40100
PRECISE PLAN
101-000441-345
port.00
;AM -TOM, (_``0Nl31 ROC' 70M AND V' LAX (`HF.,;OI:,
;I., 31:51 PREAPAIII JTRes
FEB 2 7 2003
CITY OF Ll. ;)f)I:a :A
,3'7:1,.20
$3,921.45
4250,00
°2'U.TAL PERVIT JH D'S :45 E R OW W�, r Ii .451+
RECEIPT' DATE gyp', i BY DATE FINALED INSPECTOR
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
_
—0Z �O _
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
/ V
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 Linesa
_
�, G3 i
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
Z-1- _ , _ L
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:
spm �iiS C)ti
�
s.�� I�� "e- /3, 4 -4 ciS %
JUL-03-2003 06:13 AM
FIELD VERIFICATION
Firm;
Plan Number
Sample TOUP Number
Sample House Number
„Vr�� . ,„�Ider�G.d-.AS, oGl�
Street Adaress ?g 0/9'FDyl C/) di' CitylState l
P-02
-4
Copes to; Builder, HERS Provider.
HERS RATER COMPLIANCE STAT M NT
The house was;Tested ❑ Approved as part of sample testing, but was not tested
As the HE=RS rater roviding diagnostic testis and field verification, I certify that the houses identified on this form
com y with the diagnostic Tested compliance requirements as checked on this form.
Distribution system Is fully'ducted (I.e., does not use buildirig cavities as plenums or platform returns in lieu
of ducts)
Where cloth backed, rubber adhesive duct tape Is Installed, mastic and di�ewbands are used in combination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
krMINIMUM'kEQUIREMENTS 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 fan flow is calculated as 400cfmlton x number of tons enter
calculated value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leekage/Fan Flow) Q. .5*. .2 D
Check Box for Pass or Fall (Pass=e% or less) ❑
Pass Fail
THERMOSTATIC EXPANSION_ VALVE (TXV) or Commission approved equivalent
grYes ❑ No Thermostatic Expansion Valve (or Corrunission approved
equivalent) is Installed and Access Is provided for Inspection ❑
Yes Is a pass ass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
0 Yes O No ACCA Manuel D Design requirements have been met
(rater has verified that actual Installation matches values in
CF -1 R and design on plan:
O Yes 0 No TXV is installed or Fan flow has been verified. If no TXV, w'
verified fan flow matches design from CF -1 R,
Measured Fan Flow =
O 0
Yes for both 1 and 2 is a Pass pass Fail
Certificate of Occupancy
a
Ltiwoonnhn��
last
G OFT9� 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.
BUILDING ADDRESS: 51-610 AVENIDA DIAZ
Use classification: SFD Building Permit No.: 0301-457
Occupancy Group: R-3,1.1-1 Type of Construction: VN Land Use Zone: RC
Owner of Building: RICHARD LEBRUN Address: 52-775 AVENIDA VALLEJO
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
77,z-,
Date: 7-15-2003
Building Officia
POST IN A CONSPICUOUS PLACE
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