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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
682901 k3 Com' a d 31 f
Date 11, 4 ) Signature of Contractor''( ����` 4,z
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.
S5(i) I have and will maintain workers' compensation insurance, as required by
ection 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:
Cartier ;;TA:'T1 OMInfl34,gA.'TI Policy No. ZA-00 UNIT0019787
(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: C1 Applicant .: f: . > �' !9 s 1) i A
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 oi� 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 inspection purposes.
Signature (Owner/Agent) % f <.� c' ''-°�"' '' Date�f
BUILDING PERMIT PERMIT#
DATE VALUATION LOT " TRACT
_
10 iota' 246
JOB SITE
ADDRESS � I ��
APN
14 1•-I:II21.
OWNER
CONTRACTOR / DESIGNER / EN (NEER
T BUFFM
Dt°4i+'.M L ADI INGTO11
FidDOX I:=4
41480I� R'', WTA.G M
LA QMIA 4A 922.53.
13MA%1 iA 1'2L7T EMS C:A. 921,01
H71 CKA 3724
n
.08-7528
USE OF PERMIT
1511, S.P. SYD TWIW;T DOM NOT INC.1,t3DX Ftr.,er K WUkL4 POOL Oil.
I).t21i3 AY APPROACH
TRACT CONSi?;.17CTION 1,5.11.00 OF
�
FORCi31'i. TIO �A,00 F
MRAWYCARPORT 463.00 3F
manum) con- or. coxgumcnon
C473tif>7°ni1C.f'ION F.U. 101.000.416wOFJO ��et1�.Di1
Pi" CHP?4 P' F' FFIF 101. -00C► -429-318 $5 tl.*5fl
1��yFky��:.'SIT � 101 -000-439-318 420.80
.FEE
n�
01 -000 �3:l.vt!
.• "�
E LE C T I U C A L F E E 141.0f* -420400 $111.00
PL,iJMBINO' W 3 p1. -Qui-�41 a •Ql�J, ] 3 .�e
I!Y'1'RO1+ O MO !'ION FEE - R931Ia _ 01A -000.2,41.000 $9,24
ORADINO YEEv 101•-00&423-010 $15,00
III}�i.PACt� ?�'�...Z $2,40s,00
tDlpp�iyr��'ry�ti>.�)PER
yr�,(�(9}�9 � y ids
T.'S�EC I:� , PLAN 1 fl!-Cli]F7.4, 41 -Us $1.11i1.t30
i
{ I t }...�!•`�"S PRM -PAID 1+'.E n9
4250,00
12 11
NOV 2 P, ".I±J2111
221 f�`1;1'��
CITY OF LA QUINTA
FINANCE DEPT
iy i $ :6F
RECEIPT
DATE
1 7,i, t.,
BY l
1<' Mfr
DATLE
G c
d(�
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 14Ducts
Slab Grade
Return Air
Steel V
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap -
F.A.U.
Framing
Compressor
_
Insulation — X03 _
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 `G
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_y
Encapsulation
Gas Piping
Gas Test 3 5
Appliances
Final
Final
Utility Notice (Gas)=o — —
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lbw Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Y
1 t Building vv
r -
1,'l Address , 3 ciG ,� y—
Owner
TV* 4 a& 67"
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
rx, LA QUINTA, CALIFORNIA 92253 J
Mailing GG X /3
Address ,
City Zip Tel.
L /V <2, ct-k 5 7 � ?
ress/
Zip Tel.
State Lic. City
& Classif. /A I Lic. #
Arcn., tngr.,
Designer
Address
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Che" 9 (commencing with Section
7000) of Division 3 of the Buai--- 4 Pr+•'- license is in full force and
effect.
SIGNATURE DATE
AAT1ON
I her, .� rn'thai ..m me Contractor's License Law for the following
reason: (Sec..';031.5.Bustness d,.0 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 py any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundreddollars ($500).
C', 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, Bulsness 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
or improvement 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.)
( 11, 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 contractoris) licensed pursuant to the Contractor's License Law.)
C) I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate oK consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if 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: If, after making this Certificate or 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
1hereby 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 slate 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.
Signature of applicant -Date-
Mailing
ateMailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP./
A.P. Number
Legal Description
Project Description
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 INSPECTOR
Issued by: Date Permit
Validated by: -
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Sq. Ft. No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑
Repair ❑ Demolition ❑
r
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
lip
AI yC l//N
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 INSPECTOR
Issued by: Date Permit
Validated by: -
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
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 1,521 S.F. or $3,254.94 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. 277863
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
'Fee dollected /exempted by Monica Guillen
Signature k&11�4 I 'Il Ile
$3,254.94
Payment Recd 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
U
RC DISTRICT — PLANNING REVIEW FORM
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: Tommas Buffin
SITE ADDRESS: 53-905 Eisenhower
APN . 774 _ 165 _ 021 CASE NO.: 2002-720
LEGAL: LOT 10 BLOCK 246 UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY: Wally Nesbit 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 I
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'
Other Requirements:
Ved es
Sam ...... — ----
ty Council .._---.-
b' "
lrnti
Case
Expi
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Is �' ' 4
No. 19_...:_-2&2 «... ....�..—.•
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Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following.-
BUILDING
ollowing.
BUILDING ADDRESS:
Use Classification: SFD
Occupancy Group: R3
53-905 EISENHOWER
Type of Construction: VN
Owner of Building: DAVID L ADDINGTON
Bldg. Permit No.: 0210-201
Land Use Zone: RC
Address: 41-780 HERMITAGE DR
City: BERMUDA DUNES CA 92201
By: KIRK KIRKLAND
l a-' Date: 4-24-03
Building Official
POST IN A CONSPICUOUS PLACE
APF -14-2063 06:57 AM
I/
CA
C TESTING
ProJeCt Title / Det
4
Pro'e1Address Builder Name
- } Gtr
r t �G �/;------- -- — ---
Builder Cont t Telephone Plan Number
r' 1, "". „_/,1 -1,/<)-1,/<). 7 2 1
CF -4R
HE=RS ter Tel phone Sample Group Number
C tying Signaturo Oate Sample House Number
rm;C. d- dGi r� I HERS Provider; /�G/r�,
Street Address:-7Y,4&1(i �Y�1�TdY4• Cir( g�T City/Statelzlp; G q r -Y JaJv -72Qz 3
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: 2r 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
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 Ileu
of ducts)
99'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
If fan flow is calculated as 400efm/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)
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
Iles IJ No Thermostatic Expansion Valve (or Commission approvcd
/ equivalent) Is installed and Access is provided for inspection
Yes is a pass Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
t . O Yes O No ACOA Manual D Design requirements have been met
(rater has verified that actual Installation matches values In
CF -1 R and design on plan.
2 D Yes O 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
DEC 09 '02 18 38 FR
Information
/r mTo Build On
EnglneeMg • consaldng • Testing
TO 9-7777011 P.02iO3
REPORT OF FIELD COMPACTIO14 TESTS
TESTED FOR: POWER BROKERS PROJECT: 53905 EISENHOWER
PO BOX 134 LA QUINTA, CA
LA O'UINTA, CA 92253
DATE:
October 24, 2002
OUR REPORT NO.: 073-20276-2
TEST DATA:
(1) Fine to medium
grained silty
sand. OPT.
MOIST.
= 8.09&
MAXIMUM
TEST
TEST
SOIL ID
LAS DRY
* WATER
W'T
DRY P
NO.
DEPTH ELEVATION
NUMBER
DENSITY
CONTENT
DENiITY
DENSITY CO
1
8"
FG
1
122.5
6.8
124.1
116.2
2
81I
FG
1
122.5
7.1
122.7
114.6
3
811
FG
1
1
122.5
7.5
7.4
122.1
113.6
4
8" -
FG
122.5
125_0
116 _4
TEST LOCATION: House pad.
1 SE corner of pad
2 SW corner of pad
3 NW Corner of pad
4 NE corner of pad
COMMENTS'
ERCENT Spec. 90$ Min
IAPACTION .._...
94.9 1 - A
93.6 1 - A
92.7 1 - A
95.0 1 _...A
NOTES: TESTS PERFORMED PER ASTM D2922-96 & ASTM D3017-96 "COMMENTS: 1. FILL MATS VAL A TEST RESULTS COMPLY WITH SPECIFICATIONS
DENSITIES SHOWN: Lbs. per cubic foot 2. BACKFILL 8. PERCENT C MP
ACTION DOES NOT COMPLY
WATER CONTENT: Percent of weight. 3, BASE COU.2SE WITH gPECIF1CA7110NS
PERCENT C p(yMPACTION: Base�on maximum dry 4. SU9SASE C. RETEST OF PREM$SpTEST
dem, on sample indicated by 6. OTHER ME NT E. MOISTURE BELOWWIF-CIF CATIONSATIONS
* (1) ASTM
mmObeeD1557-00 METHOD A
TEST INSTRUMENT:
REMARKS: PSI did not monitor the material placement
TECHNICIAN: Juan Nunez
THESE TEST RESULT$ APPLY ONLY TO THE SPEG?;IC LOCATIONS NOTED AND MAY ?JOT REPRESENT ANY OTHER :OCAMNS OR ELEVATIOP i.
REPORTS MAY NOT BE REPRODUCED, EXCEPT IN FULL WITHOUT VVRITTEN PERMISSION eY PROFE8SIONAL SERVid INOV$TRIES, INC.
STANDARD COUNT M: D:
ADJUSTMENT DATA M; D:
Respectfully submitted,
Professional Service Industries, Inc.
P$i;o00.2 (4)F Professional Service Industries, Inc. • 42-240 Green Way, Suite C • Palm Desert, CA 922.1 • Phone 7601341-5790 • Fax 760/341-5794