0012-127 (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
B 111.0 .�)
Signature of Contractor I i (a . �!r 0�°
I 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
peffnit:gi ,issued. My workers' compensation insurance carrier & policy no. are:
Carrier 201fA` E FMID Policy No. 169SP 4-01
(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'lcompensation laws of California, and agree that if I should bepre
subject�to-the workers:, compensation provision'sof Section 3700 of the Labor
Code;7l shall fbrthwjfh comply with those pllovisions.
Date: % i E' Applicant-/ 1
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person t D
whose request and for whose benefit work is performed under or pursuant t
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that 1, -have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of thi City to enter upon
the above-mentioned propertyoform sp�ction ` u poses.
Signature (Owner/Agent) +� 1 1� tf � IAS'"' ate_ r�=�
BUILDING PERMIT PERMIT#
0012-1.27
DATE 1 r VALUATION � ,• J LOT 10 TRACT Mlf. IS. 9V_1
JOB SITE
ADDRESSa°���A1'�t�
APN i
7�^BEY J
OWNER
CONTRACTOR / DESIGNER / EN (NEER
C P -WY FA1&.k' TRUST
ti3RADY CORM-ITM, 1014 CO. y
1915 MOKIWA BLVD
1915 max 1:�1�IA]MVIX
SAM I)MY0 C.a , 92110
&AND&GO A 92110
(,619)276.16271 CBL4't 6326
USE OF PERMIT
MiCgE FnriyZ DqdrMIG
1810 S,?. tr. ,SPE) PERMIT iDOM$ NO'C 1NCLUCIP, tit. OCK 'tk:E1d.LS, .POOL OR
DR.1V'`E AY 141PROACH
•:w
TRACT CONSTRUCTION 1,820,00 OF
FOR,t,RITA.TIO 36.N SF
C1:�11�KiElC°.�A.Ri'OR"1' +49�.(1Q Sig
.t.
V.SIUU4(° C0.61+ OF COI`7Mr:UM:ON
100,91,48 3t1
1 xRmff I". S'014hMWy
CONSTRUCTION PEPS 1011-000418-N00 8�'3.fSn
PI A14 Cf Et:Y.;'EIKE 101.000-4-39-315
FEE DEPOSIT 101.000-439.318 .5250.00
MECHANICAL FEE 101.1000-421.000 $65.50
RSL C.TRIC'.A1, f.3 101.000-420 000 S129.54
PLI MBINO1Pi71 101-000.419-000 $7415,0!3
STRONG MOTION ME, R 1D 101,0004A.ia000 %io,fa
ORADU40 F&P, 1.01.000423.000 p5.00
t)MEWPER. IM)PAC:T FRE $2,44 00
PREMSE PLAN $100.00
r
�y ��+C] q 7� -err $ ♦ y � � p �,T�
~`
�s� q y 4 q s
�
J� 0...,oI T a.,A:+L+C.i.,Sat'A .C'sL- D P.6:.Aaf °.. K
$4 1 1 l � A
IMS M%E-PAM. IWS
- e°vita ,
JULTWAT. 21 2003
r??;x uc ° IMF, HOW
$3,aw ,7'+
CITY OF LA (IUINTA
FINANCE DEPT.
RECEIPT
DATE j
BY
DATE FINALED .
INSPECTOR
_
INSPECTION RECORD
r 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=�f .p c/ _ST
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 O�
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 Lines �_ p���
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
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 AOS_ L41
Final
Utility Nom rm)
COMMENTS:
e
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 fiving, 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 1,820 S.F. or $3,894.80 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 OC/Washington Mutual Bank - Michael Grady Check No. 551511550
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Patricia
Signature
Payment Recd
$3,894.80
go.00
Over/Under
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 -
Builder Contact. Telephone
_:i -j^ �iRY/Y►dQl �l i 7610) 9/,?- S72
HE
ater elep one
ifyingg Signature Dpfe
Street Address: %gzl,b b SK4AOo -4
Copies to: Builder, HERS Provider
uate �
Builder Name
Plan Number
Sample Group Number
Sample House Number
HERS Provider: C HEX �
City/State/Zip: L u �t/I✓J f k C!% g a2�
CF -4R
HERS RATER COMPLIANCE STATEMENT
The house was: e9w Tested ❑ 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
,
com with the diagnostic tested compliance requirements as checked on this form.
AD Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu
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)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM A/
If fan 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) _ /
P
Check Box for Pass or Fail (Pass=6% or less)
❑
Pass
Fail
jo THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
g"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. ❑ 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
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Certificate of Occupancy
.2
T.df
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R
OF T1Building. &: Safety
i
.Department
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This Certificate is issued pursuant to the requirements of Section 109 of the California Building
s I
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.
u
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BUILDING ADDRESS: 52-945 AVENIDA HERRERA
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Use classification: SFD Building Permit No.: 0012-127E
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Occupancy Group: R3Type of Construction: VN Land Use Zone: CR
4
Owner of Building: GRADY FAMILY TRUST Address: 1915 MORENA BLVD
s
City, ST, ZIP: SAN DIEGO CA 92110
9
By: KIRK KIRKLAND
!dam Date: 3-17-05
`
a
Building Offici
i
POST IN A CONSPICUOUS PLACE
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