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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty bf perjury that I arri 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
773280 B
Date -� Signature of ConfractZd
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 tlie 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 R'X1?PIPT Policy No.
(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,th'ose,,"provisions. r '
jDate. rZ/;i Applicant~'•g' • ' r�� - ,1
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.
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 vpid-if e
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 cancellfiori�
.I
I certify that I have read this application and state that the above informa I
correct. I agree to comply with all City, and State laws relating to the b I in
construction, and hereby authorize representatives of this City to enter up
tlYe above-mentioned property for)'inspection purposes.
Signature (Owner/Agent P//%�Hv .��i° Date
PERMIT #
r BUILDING PERMIT -
_,�
DATE . i VALUATION q y }a •-e LOT TRACT
JOB SITE
ADDRESS 54- 4255 ANHA�Mi . P,f-'0.+s�R• IZA.
OWNER
CONTRACTOR /DESIGNER / EN (NEER
2214.1? Y37EM00D
P.Q. DO '. F 6
SANITA ANAL CA
l.ls ()"(PSTA CA 92253
(7 015@i�d=Pt'2;9 'am* t 2o.''s"i
USE OF PERMIT
1951 &;, 31111% PERMI1' lPFS t)1DCAd-1 4 -
(lIVE SAYpPyIV{HI.
1040R:;HIPATIO IKLY>k 15lt'
469,00 sV,.
'
k
:1�9 �t?:17M' F7+"t}f.tTviCTC�7
vCr'+SS'1'RUCTION FEE 101 <00411 8-00
FEE DEPOSIT 191.00.4 39-'2418 42W -10
ivli l a;PlNli`�h I P. �� �ifi�^�.Z t _000`.Ilfa
1 L<�`•C"i'bllt"dsi.1 FE, M � .. ,`3 kii<1litC► 1;4 t ..�i
P'1°rJla3'S.(:+rt� d�E 1fi"-tir?t�-�•1'.t)00
STRONG MOTION FEZ, R92"M 111.1-0100441.060 911.2 .
£4P.�s1�Ci? f3 PSE 1014)00-423 -WO $15.00
1:�;�,'�J�•F..rJ1'�f.Y, iA,��`�:�`i' .F7�T< � $2',,,r>f�,t7�
PPIE•+. )SR•:PLAId4itl.,00 :t-4� 1. 34.5 �S�3Zr. tia
Si M-TO7'A,1("XIMTRl ..)'G:Ttox r w PLAM cm,EcK
5�4,G�5.1f3
l:2121115.3 MIT.s
4115( -00
M1.Y. CUAL 11J31J1U 3!T E.S DUE J.'",O
S0,839A0
j
4PR 1 2003
rRECEIRTE QUINTA
AT A u
BY
DATE FIN EO
INSPEC OR
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
Exhaust Fans
O.IC to Wrap
0
F.A.U.
Framing
Compressor
Insulation
— 65
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
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
- Q
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
6
Appliances
:.
Final
Final D3
UU14 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:
Building
Willi/ fd' .114J AVoI&PAJ
(,1 I P.O. BOX 1504
/1 V g � 78 495 CALLE TAMPICO
�/ ( "l LA QUINTA, CALIFORNIA 92253
Owner (6W
Mailing '
Address�„a(l
t
APPLICATION ONLY
` BUILDING: TYPE`'COONST. OCC.GRP.
A.P. Number //�
Tel.
)I1T "/ /e X�/� 190
(� 'i�(/S 36Co Legal Description
yi 7yCity Zip Tel.
ci l
State Lic.City
& Classif.12 if
zv Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
`.1 LICENSED CONTRACTOR'S DECLARATION
I hereby affirmAhat Iagvficensed under proyf'scmnss of Chapter 9 (commencing with Section
7000) of Divisid 3 of-�lhe Business an Pro. �ysjon�s'Co(de, and my license is in full force and
effect. % ����.-�
SIGNATURE I'” 'r DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).
1 ' 1, 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
1 1 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
11 1 am exempt under Sec. B. 81P . for this reason
Date wn
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
f 1 Copy is filed with the city. 177 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: It. after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby -authorize representatives of this city to enter the above-
mentioned property for inspection purposes.
,✓�'-
I Signature of applicant ��,!� •.. Date
Mailing Address
City, State, Zip
Project Description
Sq. Ft. �/ �I No. No. Dw.
Size Y �iP Stories Units
New fV Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INS-C1,TOR A . I I
Issued by: Date �Permit
Validated by: MAR I 2C1131
Validation:
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE
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:
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 1,851 S.F. or $3,961.14 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 C/C 1st Bank/ Sharon Bills - Check No. 67624
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exed by Patricia Barbuzza $3,961.14 $0.00
71Payment Recd 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
RC DISTRICT - PLANNING REVIEW FORM (fo�
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine: 1)
that the, proposed housing design does not duplicate the same architectural style of any house
within 200 feet of the applicant, and/or 2) if. there is a need for the applicant to file for Master
Design Guidelines. If the applicant does need to file a Master Design Guideline, please transmit
this information to the Building and Safety Department as part of your correction list. Please
attach additional explanations as necessary.
APPLICANT: 4,9
r7
.SITE ADDRESS:
APN J - S� - Qd—/ CASE NO.:
y1
LEGAL: LOT BLOCK UNIT. S.C.@V.L.Q.
CHECK AND APPROVED BY: DATE:
Inform the assigned Building plan checker -upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Verify legal and APN information
Consistent with MDG on file (as
applicable)
MDG filing required (5 filings
since 9/3/98)
Architectural variety within 200
feet of the surrounding area:
Architectural design features
Q
roved b : e
fanning Commisslon ..-----► -�--""
p
ity Council ----w- "
ommunity Dev. Dept. ------
Ca
Ex
a No. --"---r""
ibit
Other Requirements:
------
5 y- 7 cw vAffie-yp
CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS �� r'J PERMIT NUMBER OWNER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work
of building permit. For each applicable trade, all information requested below must be completed by applicant.
persons appearing on this
Failure to comply will re:
BUILDER Q
list or their employes are authorized to wor
.ilt in a stoppage of work and/or the voidanceO,9ro)
"On File" is not an acceptable response. it
Trade / Classification
Contractor
State Contractor's License
Workers Compensation Insurance
City Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xxx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
Ixx/xx/xx)
EARTHWORK (C-12)
0A PU5 iY hAlv ! L.
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1-6
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CONCRETE (C-8)
FRAMING (C-5)
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01 L�.3
5 `63
. STRUCT. STEEL (C-51)
MASONRY (C-29)
12u
b
PLUMBING (C-36)
L.La 9k) i�: f 5
G- 3 Lc
tel.. Y
-Jr'1"& p!. No.
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LATH, PLASTER (C-35)
WC2002-6Sa (.
-?-1 -03
DRYWALL (C-9)
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HVAC (C -20)4.A-
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ZELECTRICAL
ELECTRICAL(C -10)r.-
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ROOFING IC -39)
SHEET METAL (C-43)
FLOORING (C-15)
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GLAZING
GLAZING (C-17)
INSULATION (C-2)
G Ix I'D
Gam' f-'
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6/_:-a5'63
ri
SEWAGE DISP. (C-42)
Do 2s-? 6 -L'
PAINTING (C-33)
CERAMIC TILE (C-54)
11
1 (
11
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CABINETS (C-6)
FENCING (C-13)
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LANDSCAPING (C-27)
POOL (C-53)
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OCT -02-2003 01:52 PM Imo.02
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING CF -4R
Project Title
Pro�le %t �ddress Sull�me /
C- i2—
Builder Cont ct Tele hone . Plan Numler
HERS Rater Telephone SImpie Gi yup Number
/�- y d
C ifying Signature �T'."_
Sample House Number
Firm:STC. saGi rr�� HERS Provider; J.G,/��o�_i..�
Street Address: 7,&110 �O>'d:FOKI l Clty/State/zip: ZN
•
Copie; to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: 4 Tested ❑ Approved as part of sample testing, but was; not lestec,
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this (arrn
co?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 plen0118 or platform return,; in lieu
et ducts)
Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are ui;ed in combination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM REQUIREMENTS FOR DUCT L,EAKA13E REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM 25 Pe) values
Test leakage Flow in CFM 1:/n
If fan flow is calculated as 400cfm/ton x number of tons enter t f
calculated value here. L�
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan t=1ow)
Check Box for Pass or Fail (Pass=6% or less)
�]
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
Zill"Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for Inspection
Yes is a pass
❑
ass Faii
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1 0 Yes D No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches valuEts In
CF -1 R and design on plan.
2. O Yes O No TXV is Installed or Fan flow has been verified, If no TXV,
)
/U� 4
verified fan flow matches design from CF -1 R.
°
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
G] 01
Fess Fai,
Q
Ioddc,Gn Engineering C �
6782 Stanton Ave., Suite A, Buena Park, CA 90621 (714) 523-0952 Fax (714) 523-1369
39-725 Garand Ln., Suite G, Palm Desert, CA 92211 (760) 772-3893 Fax (760) 772-3895 '
Date
Job No.
FIELD MEMO
Project Name lG --�t� �" Client: L_'e. CA
Site Address 5 y_1-1 0 rr °•-c' -d I'
Job Phone "
Work Done _
C7 �-
Test Summary / Footings Inspected
Test
No.
R_
—
Location
Elev.
Dry
Density
Moist
%
% Relative
Compaction
Ref. Max
pcf
Moist
%
lr
/Y
—
_�,
I!
1
Comments
141,
Fisld Tech. Super. or Agent r
24 hour notice reque [ted to schedule Field Technician. Thank you for the opportunity to be of service.
"'T•' cl 568E ZLL 09L .4jesep"Wj ed uappe t s e02:80 60 61 Rew
Certificate of Occupancy
4
IHoMIM,+s
G OF - 9► y p 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: 54-425 AVENIDA HERRERA
Use classification: SINGLE FAMILY DWELLING Building Permit No.:0304-054
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: RANDY BILLS Address: 54-865 AVENIDA OBREGON
City, ST, ZIP: LA QUINTA, CA 92253
By: DANIEL P. CRAWFORD
Date: October 9, 2003
Building Official
POST IN A CONSPICUOUS PLACE
It�,