0312-086 (SFD)U)
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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
7 2324 BH!C
Date f siCl Signature of Contractor�ri''
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.
,(1,)' 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 ''T §l, I�UTJT� Policy No. 1$7655"- 02
(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; l shall rthwith comply with'those-pr.0 islons.
Dae:., ` -t) Applicant I Z �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 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 representatives of this City to enter upon
the above-mentioned property for inspect' onpu^rpoaserS..
Signature (Owner/Agent) f/ Q ---'sa .� )." Date ~
BUILDING PERMIT PERMITk
DATE VALUATION L6T1�'..` TRACT
/ 1 • /i !'A3�4.436.13'.1T 14 208
JOB SITE
ADDRESS . s t� .�umw
APN
7 74-061-011
OWNER
CONTRACTOR / DESIGNER / ENGINEER
POWF�R RNANCE A980C.114C
PA.CIi? C T301v -2
PCS BOX 1.34
775E+4RCt IINTRY CT,ia:, UPIV7�, .,3TjnE i 13
LA QWNTA. C'.i"a. 92253
PALM ESE UT Qk 92211
(760408-3495 CM4 2953
USE OF PERMIT
STC#LE: 3~'A.I MY ]'sWK.3:, NG
$Fi3 - Pf!RM'�1.'; 170ES:i3f;?`P Tf�'C1,LtIT1I7: £;I.aY9CK:'b4=Ai..I.O� PC)C)i:.:Oit1 CT:C .
TRACT CONSTRUCTION 1,P13.00 3F
PORCt1IRATIO 38.00 8P .
GAR.AMCA.RPORT 490.00 SF
RSTR"T:RD C-01SI ' OF CONVIRUMI , ON
11486'x.6
Ty RMU, F:VIE SI11iliQo ARY,
CONS'1`RUCTY,014 FER 7.01-0010.418.000 $692.00
P11ALN CHECK FE.Ir 101-000-439-318 $1..59
FRE DEPOSIT 101.000.439-'318 -$250.00 '
11 EC,H.A141CAI1 1'�'I.Z 10.1-000-421-000 $06.50
E&f.C` RICALFUE . 101webo-420.000 $325,23
PL1JMf INO>"* 101-OOO-419-000 $11S.".
ST]R0?1OMOTION FEE -R�11D 101-000.241.000 MAI
ORAWN0 PEE 101-00/0-423-000 $1.5.00
DEVELOPER IMPACT FEE $3,405 00
PRWP ISErPLNN 101-000-441-:345 $100,011
aEM-71'O'T'A,T., CONI 1 UCTION A:1` D PI.A.9 M,�C_X
$4,102.23
IMS 7Pf.1T-1 AD)kiBS
4250,00
TOTAL T?T,IwMf.': 17�+�.'A°S DEW NOW
DEC
OF LA OUINTA
CITY
FINANCE DEPT. J^ {
RECEIPT
DATE, /
f
BY
-
D E FINALED
23���
INSPECT
A_
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS-
MECHANICAL APPROVALS
Set Backs
e9
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
- Q
F.A.U.
Framing
%— U
Compressor
Insulation
G
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
y o°
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
' Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
47 - 2-7 d (
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 6 re
ELECTRICAL APPROVALS
Temp. Power Pole __.toyS,
_&q.toy
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power -� Q
Final
Utility Notice (Perm) L �/G
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:
EXEMPT
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 1,918 S.F. or $4,104.52 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-1 st Bank, Dick Scott
Check No. 70507
CERTIFICATE OF COMPLIANCE'S'Z'E>�0sc
Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exe pted by Patricia Barbuzza
Payment Recd
Signature
$4,104.52 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 dat@ omwbich
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
YUN-07-2004 07:21 AM
P.03
AND
6uR0er Name
Plan Number
Semple Group Number
Sample House Number
eider: �f �,isecL
Street Address: �Mj�J6Q `'14e _ Ctty/State/zlp:
Copies to: Builder, HERS Provider
H§RS RATIR C0MP6j6NCLJT6jE—MEbIT
The house was: X 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
coy with the diagnostic tested compliance requirements as checked on this form.
Q� Distribution system is fully ducted (I,e,, does not use building cavities as plenums or platform returns In I!eu
f 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 (Maximurn 0% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow In CFM
if fan flow is calculated as 400cfm/to6 x number of tons enter,
If fan flow Is measured enter measured value here
C
Leafage Percentage (100 x Teat Leakage/Fan Flow) = 5, 0 p .
Check Box for Pass or Fall (Pass=6% or less) ❑
ass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent �L
;6"'
Yes ED No Thermostatic Expansion Valve (ar Commission approved
equivalent) is Installed and Access !s provided for Inspection
&f' ❑
Yes is a pass
Pass Fail
13 MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. 0 Yes ❑ No ACOA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -IR and design on plan.
1n
2, 0 Yes 0 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 =
O 0
Yes for both 1 and 2 is a Pass
Pass Fail
Certificate of Occupancy
Ti�hf 4 4Q*rw
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.
Use classification: SFD
Occupancy Group: R3
BUILDING ADDRESS: 53-220 EISENHOWER
Type of Construction: VN
Owner of Building: POWER FINANCE ASSOC INC
Building Offici
Building Permit No.: 0312-086
Land Use Zone RC
Address: PO BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 6-23-04
POST IN A CONSPICUOUS PLACE