0401-338 (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/ y _
_"ie
4 ��L .•- y
Date yf P ' 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).
( ) 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 STATE FUND . Policy No. $7333AS-03
(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-shZuld become
subject to the workers' compensation provisions of.tSecilon 3700 of the Labor
-;1
.Code, I shall forthwith comply with those proui9ion�-''
Date: -47,,l ,l Applicant ftp ✓ "
It r , 11._ _
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, indemnity.
& 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 inspectionpurposes.
Signature (Owner/Ageo.�"'rJint)�'J Date
PERMIT #
BUILDING. PERMIT
. 0401:338
DATE_ - VALUATION .1��� �Ys� LOT TRACT
23/24
JOB SITE
ADDRESS 034:C1,i!:T�NHC?1� EP, URIY s:
APN 174-:21-M
OWNER
CONTRACTOR / DESIGNER / ENGINEER
9?OV&P, Fi1.11mr1r
WZAUC:h�wx mt^_.
P.0. NZYX 1.34
50.eW WA8kIWG'1:`3N aT #22. f -
TA QUWk CA 92253
11-hQ71 WA CA 92253
(760)485=3269 G7.3L4 2387
USE PERRtMI}}T,,
ttOF
MA tr
1948 S. 1K SFO ITERWIT f"FS NOT INC1,ULA✓ RMC1t ' A1,►, Yt2ouspA
OR DRYV WA`l APPROACH
I �77 n F -S]
TRACT CONSTRUCTION 1.940,00 3
I?t1l?C fl>�•1'a0 16.00 FEB 0
2004
0AFtA,.MICARPORT 69.3,00 3
Cirr Of i.
J QU:NTA
HNANC::
DEPT.
WIDIA' EJ) COSH' OF CONSTTtv2R1'CTI53P
119A38,00
COMTRUC,+TION FEIN. 101-000-18-000 SWAM
PLAAi CHEt"I FEE 101-000-439-318 $1.%7.35
MEE DX14031 i' 101.000-139.318 42SUO
Rr11xCRAINUC,r L PIPE 101-00A-+623 -UOt1 $66.50
EI,EC'.T1 lOAL 1E SIit,57
109 -000-419-000 $124.00
S'a RONO 1d.(OTIoN FEE - RE111D 101-000-:z41-000 SJ 1,98
GRAD111S9 FEF, 101-000.423-000 $15.00
DEVEIA)PER, IMPACT 1,19E $2,405,00
P.[TEC1SE PLAN 101 -000-441 -.145 $100.00
SUB T'OT'AL C"C MSIR UC'11:CM A14D MW C EMCK
$4,150.07
i 9
RECEIPT
DATE A�. {�
By;
�----_
DATE FINALEDINSPECTOR
116- (/-. C);�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-_Q
Underground Ducts
Forms & Footings
4
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
O.K. to Wrap
F.A.U.
Framingr j d j"
Compressor
Insulation
1i�2�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lathe
Drywall -Int. Lath
-oe
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 I
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
Gas Test
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
Final
Utility Notice (Perm)
COMMENTS:
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District 4�CS��o
47950 Dune Palms Road ��
Q BERMUDA DUNES r
t- RANCHO MIRAGE
Date 2/2/04 La Quinta, CA 92253 d
� INDIAN WELLSLM DESERT
"+
No. 25451 (760) 771-8515 PALA QUINTA �y
101Q INDIO y�
Owner
Power Finance
APN #
774-221-026
Address PO Box 134
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit #
0401-338
Tract #
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street S.F.
Lot # No.
Street S.F.
Unit 1
23/24 54030 Eisenhower Drive 1948
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
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 1,948 S.F. or $4,168.72 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. 305301
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by "ron MCGilvrey Payment Recd $0.00
$4,168.72 Over/Under
Signature
NOTICE_ Pursuant to Government Code Section 66020(d)(1), this nre 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
�) 10:20 FATCO ESCROW DIVISION
,CORDING REQUESTED BY
.rst American Title Company
AND WHEN RECORDED MAIL TO:
Power Finance Associates, Inc.
51370 Avenida Bermudas, #1
La Qulnta, CA 92253
�- A:P:N.:.•774-221-026 �,
TEL:160 568 0656+++++++ P, 001
spas Move This Una for RacardeYa use only
GRANT DEED
The Undersigned Grantor(s) Dedare(s): DDWMFN TARY TRANSFER TAX $ ;CITY TRANSFER TAX $
( x 1 computed on the comaderatlon or full value of property conveyed, OR
Fie No.: RPD -1251147 (51)
computed on the consideration or full value less value of Ileus and/or encumbrances remaining at dme of sale,
unincorporated area; ( X ] City of La Quints, and
FOR A VALUABLE CONSIDERATION, receipt of which Is hereby acknowledged, Morris Skurka, TR and Vivian
Skurka, TR
hereby GRANTS to Power Finance Associates, Inc., a California Corporation
the following described property In the City of La Quinta, County of Riverside, State of California:
Lot(S) 23�and,24; Blac1 297' Santa Cjrmelita at -Valle La Qulnta, Unit No. 27, as per Map on File In
Book 19, Page 82 of Maps In the Office of the Riverside County Recorder.
Dated: 12109/290$
!A"
Morris Skurka TR
Vivian Skurka TR
Mall Tax Statements To: SAME AS ABOV9
-09'03(TUE) 10:20 FATCO ESCROW DIVISION
AP:N; 7T4=221-026_,.; Grant Deed - continued
STATE OF }
} ss.
COUNTY OF }
TEL:160 568 0656+++++++ P.002
File No.:RPD-1251147 (sl)
Date: 12/09/2003
On x ^ \ before
me v a/ ' L personally
appeared {
(or proved to me on the basis of satisfactory evidence) to be the person(s) whose
names) is/are subscribed to the within Instrument and acknowledged to me that hehe/they executed the same
in his4wgthelr authorized capadty(4e4and that hi*4w /thelr slgnature(sa on the instrument the personN or the
entity upon behalf of which the personN acted, executed the instrument. .
WITNESS my hand and official seal.
Signature
My Commission .Expires: Ak
Page 2 of 2
This area for official
notarial seal
Commmion * 1414446
Notary Pubfic - CaOromla
RNerslde County
u Comm. Expires Apr 29.20
Certificate of Occupancy
Lucosvotn7rv`'�
C�
OF Building Y p & Safety Department
This Certificate is issued pdrsuant 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: 54-030 EISENHOWER DRIVE
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0401-338
Occupancy Group: R-3 Type of Construction: V-N Land Use Zone: RC
Owner of Building: POWER FINANCE Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: October 11, 2004
Building Official
POST IN A CONSPICUOUS PLACE
FEB 16 '04 19:50 FR
OUR REPORT NO.:
OATS Z/)
REPORT OF FIELD COMPACTION TESTS
CL1EM: ��� ���,q ✓ c G
>:awEcr: S `/830 �i„Sp,�ii0v-vL I e Y.1
NUCLEAR GAUGE INFORMATION ANO
O LY STANDARD
f
CAIBRATION NUMBERS
VARIATION. PERCENT.+I- GAUGE AOJUSTMEIR 9A VAfpATION Mm
CALIBRATION
COUNTS
FROM SNEf:'i5
LAST use
GAUGE TYP • T l CAMVBELL
MOISWIte & q-5-'
MOLSTURE: f
MOISTURECMOLMRE.
CO
MODEL NO.: 5 1430
DEMsrrv,3 Zzq
OfhfiRY:
oEJiSffh; DENSITY-.
SOIL ID Jt VISUAL CLASSIFICATION OF SOIL MAX. DRY DENSITY, PCF OPTIMUM MOISTURE. %
//
COMPACTION
REQUIREMENTS, %
MOISTURE
REQUIREMENTS,
I
GENERAL LOCATION:
I
TEST
NO.
READING
QUOTIENT!
PCF
SOIL
ID NO.
TEST
DEPTH. IN
ELEVATION
OF TEST
MOISTURE
CONTENT.
%
WET
DENSITY.
PCF
ORY
DENSITY.
PCF
PERCENT
COMPACTION
COMMENTS
/
Ger
�, Z
D- �s i �
Y
M-
�
D-
I
I
M_
D-
M-
D-
I
TECHNICIAN: �' (� �!`� J %� flC e � j
v �� J/
M h rA MA ' RIAA. MPL N SPECI A O S
Z BACKFILL 8 - COMPACTION PERCENTAGE DOES NOT COMPLY WITH SPECIPICATION5
- BASE COURSL C - RETEST OC PREVIOUS TEST
a - SUBBASE 0 MOISTURE IN EXCESS OF SPECIFICATIONS
S > SOIL CEMENT E MOISTURE BELOW SPECIFICATIONS
6 OTHER
WHITE -OFFICE YELLOW -INSPECT. PINK -FIELD FILE
** TOTAL PAGE -02 **
3EP-122004 04:59 PM
CERTI LATE OF FIELD
P, l
Proiect Aodress
P.01
TION AND DIAGNOSTIC TESTING CF -411
)L
Builder Cont ct Telephone
l�� - 57; 3
PERS,Rater _ Teleohone
Date
a¢�t. ��4r't1kS. XlS dCry�l
Builder Name
Plan Number
Sample Group Number
rtifying Signature blate Semple House Number
F�rm:.J~C. d 'SSOGi eS ` HERS Provider; �G,.F i7jS5dc 476,
Street AodreSS: ��Q Aeneef FC ad 6-/i (- City/State/Zlp:; Zg 6411,r.- cd Ti 5
b
Copies to: Builder, HERS Provider
HER RATER COMP61ANCE St,6TgMENT
Tne house was: jZ Tested ❑ Approved as pdrt of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, l certify that the houses identified on this form
co;�ly with the diagnostic tested compliance requirements as checked on this form.
Distribution system is fully ducted (i,e., does not use bullding 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 leeks 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 Flow1n CFM YT,
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) = J' 57r,
Check Box for Pass or Fail (Pass=6% or less)❑
ass Fail
L THERMOSfiATIC EXPANSION VALVE (TXV) or CotTtmission approved equivalentw
5rYes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access Is provided for inspection
Yes is a pass
0 MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
Q Yes O No ACCA Manuel D Design requirements have been met
(rater has verified that actual, installation matches values in.
CF -1 R and design on plan.
2. ❑ 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
p%W
O O
Pass Fall