0309-016 (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
682901 B 12/31/2(
Date''/ / n 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). f
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044,�Business & Professionals
Code). w`
( ) I am exempt under Section B&P.0 -fj 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 cons e -to self -insure for workers'
compensation, as provided for by Section 3700o"f,'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 13TATFE PU14D Policy No. 229- 0!1OM37-2003
(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
Code, I shall forthwith comply with those provisions.
Date:Applicant
�...
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 perso
whose request and for whose benefit work is performed under or pursua f�q
any permit issued as a result of this applicaton agrees to, & shall, indem A/
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null,and voi f
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellati n.
I certify that I have read this application and state that the above informatio is
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date 2'
"BUILDING PERMIT PERMIT"
DATE VALUATION LOT 03M-016TRACT
6 FLK 230
JOB SITE
ADDRESS W-4,113 VF'MA IM.RRERA
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
THO" BufFIN
DAVID 1,. A1Y'DkT(31X)1%T
P.O. BOX 134
41.780 I3'I;"1 M1TACEDR
1A Quwm CA 92253 S3
BE;RMUD.A. sDiJN= CA 92:201
F
(760)403.7528 CTL9 37Zt
LX
USE OF PERMIT /// / j t
MNC ff P? Ly D� T9(C
1560 SY. S' 0, PERWIT ]DORS RIi3`t INCLUDE BLOCK 1►V411, IyMUSPA
OR. DRIVElY,APg.It��ACH
n
T, CT CONSdUCTION 1,366.00% F
G"
P CHIPATI 32.00 qF
%)
0. nA(iEfCAR, - RT 462.00 SF
/
II°S'S.tl 4grED COST- air C:l71VS'[T uc-170H
94,108.80
YEiMT Ir' ' F SU114KARY
,
CONSTRUCTION FEE. 101-000-148-000 $617.00
_.
PLAN CHECK IEE -1 O1 ,, E $513.49
'
I'E DEPOSIT 101.,0004-og•318 4150100
MECHANICAL ".,X 101-OCIO•Q 1-OOO $59.00
EMTI ICAL FEE 101-000--420-000 $112.34
PLUMBINO FER, :01-000 -�,1..J-000 $118.00
2rf RONG MOTION FEE - RESID 101.000.2,41.000 $9,62
(WAVI'NG FEB 10-1-OOH23-000 3-000 $15.00
DEVELOPER IMPACT FEE C -f SM -05100
101
PRECISE PLAN -000 -AAI -345 �1I00.t40
p SUB TAL.�C0N"NRTJ t ON AND PTaAkT CvfMCK
$3,949.25
LESS PRI -PAID )mB
42,50,00
SEP 16 2003 farAL P 'yggIr 1WES WE Now
CITE` '!?F t -A
RECEIPT
DATE
Byrr
INALED
DATCT
IN PE
U
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Q
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air -
Steel
Combustion Air
Roof Deck
aT
Exhaust Fans
O.K. to Wrap /
.03-
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final a
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pbg. Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines Y(2,X
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
w
Final
Final
Utility Notice (Gas)
ELECTRICAL
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)
APPROVALS
IF
G
COMMENTS:
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:
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 1,560 S.F. or $3,338.40 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 CCNIB-David Addington Check No. 287440
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia Payment Recd
$3,338.40 Over/Under
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
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
MAR. -18-2004 04:03 PM
Firm:. . d- ssaeid' _
Street Address: 2,V662 Xe&ZFo✓L Cr_k&
Copies to: Builder, HERS Provider
P.01
Plan Number
Sample Group Number
Sample House. Number
HERS Provider; J -C_4 -A!54: fLS
City)State►Zlp: La c2klnre
HER TER COMPLIANCE STATgMENJ
Tn a mouse was: Tested. ❑ Approvedas part of: sample testing,. but was not tested
As the HERS rater providing. diagnostic testing and field verification, I certify that the housesIdentifiedon this form
comply 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)
I
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.
Z MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION: COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test. Results (CFM (x.26 Pa) values
Test Leakage Flow In. CFM
If fan flow is calculated as 400cfm/tonx numberoffons enter
herei
calculated'value
If fan flow is measured enter measured value here
Leakage Percentage (1.00 Test Leakage/Fan, Flow) v L+ b
X
Check Box for Pass or Fail'(Pass=6%or less)
❑
ass Fail
eTHERMOSTATIC EXPANSION VALVA_ (TXV) or Commission approved equivalent.
eKYes ❑ No Thermostatic Expansion Valve (or Commission approved
v equivalent) is Installed. and Access Is provided for Inspection
A
Yes is a pass
Fall
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN' COMPLIANCE CREDIT
1. Q Yes ❑ No RCCA Manual D Design, requirements have been met.
(rater has verified thatactual installation matches values In
CF -1R and design on plan.
2.1 ❑ Yes 17 No TXV is Installed or. Fan flow has been verified.. If no TXV,
verified fan flow matches design from CFA R.
Measured Fan. Flow =
Yes for both 1 and 2 is, a Pass
Pass Fail