0401-337 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
O ch License # Lic. Class �'� fExp. Date
LU 0$184 'fig: /Jl,..•' 07/3111;
t,,,,.ate•
Z ir� /Datel/ 2* J Signature of Contractor
i CDp?�
OWNER -BUILDER DECLARATION
J
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z_ ( ) 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).
ce) () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
ON
O
CL Q WORKER'S COMPENSATION DECLARATION
o rr I hereby affirm under penalty of perjury one of the following declarations:
r H O O 1 have and will maintain a certificate of consent to self -insure for workers'
X W L: compensation, as provided for by Section 3700 of the Labor Code, for the
i O � Q performance of the work for which this permit is issued.
m Q O ( ) I have and will maintain workers' compensation insurance, as required by
I O (-)Section 3700 of the Labor Code, for the performance of the work for which this
a rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier STATE F(l1•1D Policy No. 173 1.0;
r- C3
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 soas to. become subject to the
workers' compensation laws of California, and agree't_hat„if) I should become
3 subject to the workers' compensation provisions of,.Section 3700 of the Labor
Code, I shall forthwith comply with thostprovlsions.
Abate: 1-2711g � �. -1 Applicant
Warning: Failure a 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 fo nso__J urposes.
-Signature (Owner/Agent`--'"� Date (A h
L
BUILDING PER PERMIT #
0401-337DATE-�
r VALUATION $1 ,1400-1.60 LOT LOT 5 TRACT
JOB SITE
` ^
ADDRESS w 82,5 .S1. ZJ41l[0V[FR D1 iVE
APN
774-1,165-01154
OWNER
CONTRACTOR / DESIGNER / EN INEER
P,O. BOX 134
50<855 4V1 AS1-RNQ NST #227
Z.!,. C1tWA CA 9225.3
LA Q1T,`IZ-A CA 92251
(760)4:35-9269 tICEIIA 23$7
USE OF PERMIT
�iLi�l'C3i:.,1�' Ti ?�J+�:�° I��JI�?T.i„I;�7C1•
1913 S. f? SFi) PKftMIT GtCIV; NOT THCL U13% F4 LOCK WA.iy1., POOL S.PtA
OR DY N FW AY APPROACH
11
II /r
TRACT C0143TRUCT1011 11918.00 5
PORC;kdtPMIO 5d.°;
cS:�.BiAGE/CARPOR.'1' X189.0.0 81 FEB 0
LJ
2 2004
CITY OF L
A QUINTA
FIRANC
_
DEPT.
Eli C(AVT OF Cv'O1'3N'TRIJf'`1�01h'
1.14,007M
q^ q rl�, 1 �. �+�s S ef•Lr� tt � 3 ,y 1[A�:�"'IT�l1'A.'1
.fc'ai;C'i1.VU h .4 �c� E 9VS.�atvoAJZ.3
COM0,1'RUCT10N FIRE 101-000-418.000 $592.00
PL1�14 CHECK 1'"EL1 )01-000-439-318
11"EVE DEFGSI'i” 101.000-439-31,3 .8250,00
NfOr:HA'NICAL .ME 1101. • 000-.421-000 $6630
E.1,,EC.'•TR'fCAL ."39 101.000.420-000 $125.23
'01,lJMliINO FEE 101-000-419-000 $124.00
OTRONO MOTION FRE . R ID 101-000-241.000 $11.40
f)ftAylNa FEE !X31.000.425-000 $15.011
LIEMT �OPZR MPACT Fr E %M6510
PgrMISE PIL&I.4 1101-00013-441-315 $lOil.C(i
SUB -TOTAL COMMAIR T: OW AND :E>%.A33' CHEM
$4,112.84
:(d1-0 PRE-VAID FEES
4,0150,001
'%'O":rAL PE, RK1rFRIFISDsvE NOW
94�*2.04
RECEIPT
DATE�M
/
DAj6fI 77 O `
-- //XA
INSPECTO
j
Uvyy��
`k
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.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
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
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
IF
Gas Test
O
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 _ — Or'
Final
Utility Notice (Perm)
COMMENTS:
Date
2/2/04
No.
25450
Owner
Power Finance
Address
PO Box 134
City
La Quinta Zip 92253
Tract #
Type
Single Family Residence
Lot #
Unit 1 5
Unit 2
Unit 3
Unit 4
Unit 5
Comments
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
. (760) 771-8515
No. Street
53825 Eisenhower Drive
S.F.
1918 Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
4���1Flr-Dsc�o
" W"M1 o
< BERMUDA DUNES r
GO RANCHO MIRAGE d
INDIAN WELLS
PALM DESERT y
LA QUINTA 4
QINDIO yJ
O
APN #
774-165-016
Jurisdiction
La Quinta
Permit #
0401-337
Study Area
No. of Units
1
Lot # No. Street
S.F.
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 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 1,918 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 CC/Valley Independent Bank -Mike Brauckmann Check No. 305302
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted ron McGilvrey. Payment Recd
$4,104.52 Over/Under
Signature c
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the W -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 - ApplicantlReceipt Copy - Accounting
0 0 Certificate of Occupancy0 o
ui�cv
G� OFBuilding & 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: 53-825 EISENHOWER DRIVE
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0401-337
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: POWER FINANCE Address: PO BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND -
Date: AUGUST 17, 2004
Building Official
POST IN A CONSPICUOUS PLACE
l
UG -11-2004 07:26 AM
P
uilder
'FICATE OF FIELD VERIFICA
iD DIAGNOSTIC TESTING
iD
Builder Name
Plan Number
e Sample Group Number
P.01
CF
ifying Signature to Sample House Number
irm; STC. d-�SSoGi�%s HERS Provider; �G_�f-%�S�oG/�it:S
Street Address,7 7,ygr Clty/State/Zlp: La Quihr 60 9;z2,S3
Copies to: Bullder, HERS Provider
HERS RA ER gOMB616Ngg STAT§MEN
r
The house was: 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"Ply 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)
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 B% Duct Leakage)
I Measured
Duct Pressurization Test Results (CFM Q 25 Pe) values
Test Leakage Flow In CFM �O
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) _ a
Check Box for Pass or Fall (Passae% or less)
O
s Fall
L THERMOSTATIC EXPANSION VALVE (TXV)or Commission approved equivalent _
as ❑ No Thermostatic Expansion Va
equivalent) is Installed and,
❑ MINIMUM REQUIREMENTS FOR DUCT DES
1. ❑ Yes ❑ No ACCA Manual D Desll
(rater has verified that
CF -1 R and design on
2. ❑ Yes O No TXV is Installed or Fay
verified fan flow match
Measured Fan Flow =
'(or Commission approved
:ess Is provided for Inspection
Yes Is a pass
3N COMPLIANCE CREDIT
i requirements have been met
Ictual Installation matches values in
Ian.
flow has been verified. If no TXV,
is design from CF -1 R.
Yes for both 1 and 2 is a Pass
eJ
❑
Pass
Fail
/
❑
❑
Pass
Fail
Feb -13. 2004,E 9;21AM2 FRCONTEMPORARY I TO 95686072 N0,4386 P.P. 33
•
REPORT OF
FIELD COMPACTION TESTS
OUR RETOOT NO,:
cum: ,Ip>✓.c.IL
DAM z , O
PIIt1IECY: $-3 rzr
"4141i WPORMATION AND
FAU
DAILY CTANDAAD
COUNTS
CAISRATION NGr� WNVAMAT. PmcrwT.-/- WGE ADAISTIMEI/TVARIATION RAMYBRATION
FROM SNFPISIAST USE
TLAIAR
CE V X AMPVSU
NO,.—s 43 D
M04rTViI£�
OfllSrrY:
MOlSTV118
09/Sm:
MO15WRE,
OcuRV•
MOISTU RE,EL
Q'iNiI11i
A ORI MA 1 Iq
SOIL 10
VISUAL CLASSIFICATION OF SOIL
MAX. DRY DENSITY, PCF
OPTIMUM MOISTURE. 96
COMPACTIONMOISTURE
GENETI
RAL LOCAON:
Eaumm. % �
Rcm i
REQUIREMENTS,
TEST READING QUOTIENT/ SOIL
NO, PCF IO NO,
T867 MEVATION
DbTF+, IN Or TLST
MOISTURE WET
CONTelfr, DENSITY,
DAY
OENS(TY,
MCENT
COMPACTION
co
% PCK
P{',F
M-7
D- I/ll
g•�
��
�gT
�,S INS • f
140
1%,a
3A--
Ti
M-7 Z
0
_
D-
M�
o-
M-
D-
M-
D- I
M-
1
�t l�
TN SPEWICATIONS
E 006 NOT COMPLY WITH SKCWICATIONS
PECIFICATIONS
ATIQNS
** TOTAL FAGE.03 **