0212-148 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm'under penalty of perjury that I am licensed under provisions of
dhapter 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
.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).
(- ) l,' 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 Sionature - 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(/) 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 STfi TL � N Policy No. �4. DD1 na7• t (13
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
subject to the workers' compensation provisions of Section 3700 of the Labor
3 Code, I shall forthwith comply with those provisions.
� -Il ate: L -10- c, 2) Applicant 1oln sirr�,t Xjl,; Ili,-, }rte,;,
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 .tothe conditions and restrictions set forth on his::
application.
' 1. Each person upon whose behalf this application is made & each persdn'at`
i .'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.
1'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'inspection purposes.IF
i
gnature (Owner/Agent) �r `" Date//
BUILDING-, PERMIT PERM T#
DATE VALUATION ' LOT TRACT
JOB SITE APN
ADDRESS -941 i lx° Vtj MD..AV111 A 7713344M
OWNER CONTRACTOR / DESIGNER / EN &NEER
41-780 MU't+AI AOM M. � 41 �731t :�+" ��,�3;�� D;P.
zr3 t Tl Saes 17i�` ; �,F CA: B'ERIAWre 735.NE-113 � CA 92201
1 ('1,663}448.0526 0 -AN 3724
USE OFr�PERMIT
q p� p, .pit q,y p*� .rye ,f+� �•y
e�,1.CV V.S.oSr •�CeLC! U.s7; .JJ'�.�.''.�i.nL.r1L�W' �C. �'( t''1
3421 tr),IR SIMI.
TRACT CONSTRUCTION 1,421,00 8F
POFt I.9PATIO / 33.011 sr
0.AP,A0rJX=P0RT WIN! 3 ;F
' i �S�:a) co OF Ci:A�1wrRi�Cr�' ow
MA14 CHECK M11 -1Z 00,pl;-4,39-318
FEE D.1wPOSIt' 30.0
1f,990MN1C',A ,YEE MOO
ZISIC"!',IUCAL N'�
PLUMBi1-10 PER 101 -000-419vWO
antosomorcm va, REBID 101 -000 -24I. -OW,
0, RA aTO0 M .. 101-000-423.000
prai-I ISE PLAN i�i� -!��?-•x,41'-34s ra a� �tUO.tdf3
i .
LESO TME. -PAW, FEW 4750.00
DUF_ BOW
Cl
F�NOF� �f/•
RECEIPT RJ�Y y BY �- DATIjFINALED INSPECT
ZZ.CJ 3
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-
Underground Ducts
Forms & Footings
Ducts
Slab Grade
/
Return Air
Steel
_
Combustion Air
Roof Deck
o 1190-01--
Exhaust Fans
O.K. 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`f
_
"
_
Final "TT 03 _
BLOCKWALL APPROVALS
Final
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 / . Q
Encapsulation
Gas Piping
Gas Test
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) p3'
COMMENTS:
�✓�- !�v/-� L i l 7 0-7
,,,- .CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District quo
47950 Dune Palms Road °'
q Q BERMUDA DUNES C^
'Date 1/22/03 La Quuinta, CA 92253 C/D RANCHO MIRAGE. 0'
INDIAN WELLS
No. 24053 (760 ) 771-8515 PALM DESERT y
LA QUINTA
..�INDIO
'Owner David Addington APN # 773-334-004
Address 41780 Hermitage Dr. Jurisdiction L2 Quinta
City Bermuda Zip 92201 Permit #
Tract # BLK 148 Study Area
Type Single Family Residence No. of Units 1
Lot # No.. Street S.F. Lot # No. Street S.F.
Unit 1 23 5281.0 Avenida Villa 1421 Unit 6
Unit 2- Unit 7
Unit 3' Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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 :he 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 praect may now be issued.
Fees Paid By CC/Valley Independent Bank - David Addington Check No. 278047
Name on the check Telephone 760/408-7528
Funding Residential .
By . Dr.. Doris Wilson
Superintendent
Fee collected /exempted by Monica Guillen
$3o.o.
,040.94 0
Payment Recd Over/Under
SignatureAln-11G
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 projBct 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. Departrrent/Applicant Copy - Applicant/Receipt Copy - Accounting
Im
FEB 04 '03 13:38 FR TO 9-7777011•
L'M►i Infos nd tion
oToBuild On
Engineering • Consuffing .li, Testing
P. 02/02
REPORT
OF FIELD COIVIPACTIUPI TENS
TESTED FOR: POWER BROKERS
PROJECT: S2-810 AVEDIDA VILLA
PO BOX 134
LA QUINTA- CA
LA QUIN•TA, CA 92253
DATE: January 13, 2003
OUR REPORT NC.:073-30011-=
TESTDATA: `(1) Fine to medium grained
silty sand.- OPT. MOI:iT- _ 11.0%
–
-
MAXIMUM
i
COMMENTS'
-----
— --
TEST
TEST
SOIL ID
LAS DRY *
WATER
WET
DRY
PERCENT
Spec.. 903 Min
N0.
DEPTH
ELEVATION —
NUMBER
DENSITY
CONTENT
DEN; ITY
_ DENSITY
COMPACTION
1
all
FIG
1
115.5
9.4
12?.4.
111.9
.96.9
1 - A
2
811
FG
1'
115-S
9-8
1231.7
109.9
95.2
1 - A
3
8'f
FG
1
115.5
10.3
122-0
110.6
95.8
1 - A
4'
811
FG.
1
115.5
10.0
121.3
113.0
97.8
1 _ A,
TEST LOCATION: House pad.
1 •.
SW corner
2
NW corner
3
NE corner
�•4
SE corner.
----- _..
_
NOTES: TESTS PERFORMED PER ASTM 02922.96 & ASTM D3017-96
'COMMENTS: • 1. FILL MATERIAL A. TEST R�ES ``TSg COMPLY WITH SPECIFICATIONS
COMPACTION
DENSITIES SHOWN: LbS. per cubs foot
2, BACKFI�L B. PERCENT DOES NOT COMPLY
3. BA E C OF SE WITH SPECIFICA IONS
WATER CONTENT: Percent ofd weight.
PERCENT COMPACTION: Basewon maximum dry
density oblainpO on sample indicated try
4. SUBBASE C. RETESY OF PREVIOUS TEST
5. SOIL CEMENT d, MOISTgJRE IN EXCESS OF SPECIFICATIONS
MoV155TURE BELOW SPECIFICATIONS
SOI ID number,
6. OTHER E.
* (1) ASTM D1557-00 METHOD.A
TEST INSTRUMENT:
STANDARD COUNT M: D:
REMARKS: PSI did not monitor the material placement.* ADJUSTMENT DATA M:. D:.
Respectfully submitted,
TECHNICIAN: Juan Nunez
Professional Service Industries, Inc.
Tm1SE TEST RES"T8 APPLY ONLY To YHE SPECIFIC LOCATIONS NOTED AND MAY NOt REPRPSENT ANY OTHER LOCATIONS OR ELEVATIONS -
REPORTS WY NOT Be REPRODUCED, EXCEPT IN NIL.'AnTMO(1T WRfTTEN PERNSSION
BY PROFESSIONAL SERWCB INDUSTRIES, INC. (
Professional' Service. Industries, Inc, 42.240 Green Way, Suite C • Palm Desert, CA 92211 • Phone 760130 -57M • Fax 760/341.5794
PSI A-100-2 (4)F
** TOTAL PAGE.02 **
MAY -12.-2003 03:53 PM
CERTIFICATE OF FIE><,D VERIFICATION AND DIAGNOS
Project Title
x-, i SW o ilrt _
, Telephone
Bu
'0
Builder Name
Plan Number
t 1ep�or,Q Sample Group dumber
ASter J
e Sample House dumber
Signature G J- ®GC. � HERS Provider:
Street Address: % e' q '0Y / elwStateizip:' �N
Copies to: Builder, HERS Provider
HERS RATE13 COMCLIANCEE
The house was: rTeisted Cl. 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
I omply with the diagnostic tested compliance requirements as checkedon this form.
Distribution system Is fully'duoted (i.e., does not use building. cavities as plenums or platform retums in lieu
eof 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.
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE=CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage) c
Measured =
Duct pressurization Test Results (CSM @ 25 Pa) values
P.01
hA 150 3.
CF -4R
' Test Leakage Flow In CFM -7
If fan flow is calculated as 400cfmlton x number of tons enter /t1
calculated value here
If fan flow is measured enter measured value here .�
Leakage Percentage (100 x Test Leakap/Fan Flow)
Check.Box for Pass or Fall (Pass=6% or less)
0
Pass
, Pail
THERMOSTATIC EXPANSION VALVE (TXV or Commission approved equivalent
_
No Thermostatic Expansion Valve (or Commission approved'
Yes -
equivalent) is installed and Access Is provided for Inspection
Yes is a pass Pass
Fall
d MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT ,
1, Q Yes M No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values. in
CF -IR and design on pian.
2. ❑ Yes C7 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=
E3
O
Yes for both 1 and 2 is a Pass Pass
Fail
1
X(Certificate o.f.Occupancy.
City of La Quinta
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: 52-810 AVENIDA VILLA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0212-148
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: DAVID ADDINGTON Address: 41-780 HERMITAGE DRIVE
City: BERMUDA DUNES, CA
By: KIRK KIRKLAND
Date: MAY 13, 2003
Building Official
POST IN A CONSPICUOUS PLACE