0210-087 (MISC)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
Date 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:- .-•- - - � -
(yJ 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).-. >Veoe .• , ;!".
O I am exemptlunder Section B&RQ";l r thIs,reas6n
AaterfO�d' Signature of Owner �' d=¢'� /�•
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.Policy No.
(This section'need.not be completed if the permit valuation is for $100.00 or less).
(}Y I certify that in the performance of the work'for which this permit is issued,
If§hall not employFany.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 provision's of.Section 3700 of the Labor
Code, I shall forthwith comply with.those provlslonS.
,Date: '
�:,�• - fir'' /• �,j
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 F
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 Quints, 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`'reest'atives of�fhis City to enter upon
the above-mentioned .pro`perty for inspection pufpse's'
Signature (OwnedAgent)•
PERMIT`�#21
' -tiny BUILDING -PERMIT.
0-087
DATE ' .'-r• "• '` VALUATIA — � LOT TRACT
JOB'SITE
ADDRESS ` 1p -Ws a+a, C::17MO
APN'
–
OWNER
CONTRACTOR/DESIGNER/EN INEER
11 113 ACA y
413-149 V!DTACMO
b5� ��C'►TAi'A CA 02253
_
USE OF PERMIT
WAS CM IDWE0 US
121 ;{8'�Jil t? f tCJ STk2dS3 �1 c i13t7" �Ai3U )f6 2l g OF`t 1�:i t) FWNCH. NCH. i"3OO S.
VALUATION 1,IsG0.Ofl Wq
d. �.:! or�lJN *`c�L' 4 L.r.•'t�x7�A.lGS.i.+ME01
�y�j6 v�. yrq g� ap�gpy��q�'7p.LSs�by�.A14',T
P.N�6.l4L.G C. X1 S4x1:+, JJ.431W AJ'R.Y"Y
PW4 CH.Gla V9z 101.0 0.4399.318
CON51'€tucrion nrz $450
h'
?1jC 1` ON AND YLA9 Ck IF.I
$14.2:
CITY OF LA QUINTA
FINAPICE®EPS . ,
RECEIPT
DATEr J
BY . -
-DATE FINALED
INSPECTOR
i, { t
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
tower 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:
////
C"Oev
14,30-'�7
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
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1 �� ��cv S
Act SEW -� LOCA �a11 s;J t
4 . , 2 . dig► � �Az�aG � �e�Erl�� e1Gv� ; ��,��� ` . , .
ore
DOORS r— G 118 5
D .51AC4G af-'o•40 ,oe L., G g
DrRAWZ MG HQT TO
8A
E3 A
GARAGE
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acted by LUDWIG R GARIATZ . License No..F -28855
Signature .
Tt: Questions or problems concerning the above reoort shnultl-hf- rii'm marl rn rF,a.%C r.l.,,
I
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 1 of 3) CF -1 R
� E Y — Fe26Nc K � 004
Prodre� ttlry9 V/,s /-.4 C(6 e- Date
Projec Add/dre
A Carse y
s Building Permit
t
Do pentation Author Plan Check / Date '
r � EcA-p T e, V,E Telephone
Field Check! Date
Compliance Method (Package or Computer) Climate Zone
Enforcement gency Use Only
GENERAL INFORMATION
Total Conditioned Floor Area Z7 ft, Average Ceiling Height: ft
Conditioned Slab Floor Area ft'
Building Type: Single Family Addition
(check one or more) Multi -Family Existing -Plus -Addition
Front Orientation: _ North / South / East / West / All Orientations'
(input front orientation in degrees from True North and circle ole)
Number of Stories �_ 1
Number of Dwelling Units: -
Floor Construction Type: Slab/Raised Floor (circle one or both)
RADIANT BARRIER (required in climate zones 2,.4,8-15) Required for this submittal_ yes )—ono '
BUILDING ENVELOPE INSULATION
Component Frame Type Cavity Sheathing Total R- Assembly Location/Comments
Type wd = wood Insulation Insulation Value U -Factor (attic, garage, typical, etc.)
stl = steel R -Value R -Value
Wall
Wall
Roof
Roof
Floor
Floor
Slab Edge
�•nr ...e .. .1: T_.
- - -- - -- -•• s IIUI IG u,lcu ror a woos -names wau that meets cavil R -value
insulation reabirements for the Prescrintive Package
FENESTRATION
V1/GL�1111LV V I%..GJ
Fenestration Orien- Area Fenestration Fenestration Exterior Overhangs/
#/T a/Pos. tation (ft 2) U -Factor SHGC Shading Att. Fins
Front 5 1. 8 0, 75' to
Front
Left
Left
Rear
Rear
Right
Right
Skylight
Skylight
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page•2 of 3) CF-1 R
Project Title Date
HVAC SYSTEMS
Note: Input hydronic or combined hydropic data under Water Heating Systems, except Design. Heating Load.
Distribution
Heating Equipment -Minimum ' ` Type and
Type (furnace, heat Efficiency Location
pump, etc.) (AFUE or HSPF) (ducts, attic, etc.)
Duct or
Piping Thermostat
R -Value Type
•
Heat Pump
Configuration
(split or package)
/V 0
Cooling Equipment Minimum Duct
Heat Pump
Type (air conditioner, Efficiency Location
Duct Thermostat
Configuration
heat pump, evap. cooling) (SEER) (attic, etc.)
R -Value Type
(split or package)
X1/0 l' fi-/i N � C'• _
-
'
SEALED DUCTS -and TXVs (or Alternative Measures)
❑ Sealed Ducts (all climatrzones)
(Installer testing and certification and HERS rater field verification required) ..
TXVs, readily accessible (climate zones 2 and 5-15 only)
-:
(Installer testing and certification and HERS Rater or field verification required)
_
Li Refrigerant Charge/Air Flow (climate zones 2 and s-15 only) •
(Installer testing and certification and HERS Rater or field verification required)_
,
OR
0 Alternative to Sealed Ducts and TXVs (see Package C or D Alternative Package Features for Project Climate Zone)
Climate Zone ` Window SHGCWindow U -Factor,
SEER Heating
WATER -HEATING SYSTEMS
Energy' _ . External
- Rated' Tank Factor or Tank
Water Heater Distribution Number Input (kw Capacity Recovery Standby'. Insulation
Type Type in System or Bui/hr) (gallons) Efficiency Loss (%) R Value
1. For small gas storage water heaters (rated inputs of less than or equal to 75,000 Btu/hr), electric resistance, and heat pump water heaters, list Energy
Factor. For large gas storage water heaters (rated input of greater than 75,000 Btu/hr), list Rated Input, Recovery Efficiency and Standby Loss.
For instantaneous gas water heaters, list rated input and recovery efficiencies. "
SPECIAL FEATURES (add extra sheets if necessary). Package C and D: TXVs, Sealed Ducts, Radiant
Barriers (see installation requirements for radiant barriers in Section 8.13 of the 2001Residential Manual).
Package C: thermal mass (thermal mass type, covering, thickness, and description).
CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 3 of 3) CF-IR
Project Title Date F
COMPLIANCE STATEMENT
This certificate of compliance lists the building features and performance'specifications needed to comply with
Title 24, Parts 1 and 6 of the California Code of Regulations, and the administrative regulations to implement
them. This certificate has been signed by.the individual with overall design responsibility. When this certificate
of compliance is submitted for a single building plan to be built in multiple orientations, any shading feature that
is varied is indicated in the Special Features/Remarks section. The undersigned recognize that compliance using
duct sealing and TXVs requires installer testing and certification and field,verification by an approved HERS'
rater.
l
Designer or Owner (per Business and Professions Code) 'Documentation Author .
Name: C YW 17/ZQ/ S� .l7 Name:
Title/Firm: _ �Title/Firm:
Address: / 54A Address:
Telephone: %� �J� Lf Telephone:
(Si a da (signature) ' t, (date)
Enforcement A cy
Name:
Y
Lam Q c
5
CSM
OF78-495.CALLE TAMPICO —,LA QUINTA,.CALIFORNIA 92253
TELEPHONE (760),777-7012 FAX (760) 777-.7011
OWNER/ BUILDER INFORMATION
Dear Property Owner:
I: An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified. }
For your protection you should beawareVthat as ''Owner/ Builder" you' ate the responsible party of record on such a
"1! permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your, work is being performed by someone other than yourself; .you may protect, yourself -from possible,
i liability if that person applies for the proper permit in his or Tier name.
Contractors are required by law to be licensed and bonded by the State of;California and to have a business license'
from the City or County. They are also required. by law to'put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of variuus'trades that you plan'to subcontract, you should be
` aware of the following information for your benefit and protection:
I' If you employ or otherwise.en a e an ersons other than our immediate family, and the work (including materials
�< Y P Y g g YP Y Y, i•. , g
and other costs) is. $200.00 or more for the entire project, and such persons are riot licensed as ,contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject .
to several obligations including State and Federal income-tax withholding, federal social security taxes, worker's
' ^ compensation insurance, disability insurance costs, and unemployment compensation contributions.
�.: a ' -
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance. ;
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business A'dminstration). For more specific information about your obligations under State
Law, contact'the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through. their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
it • permit, erroneously implying that the property owner. is providing his or her own labor and material personally.
ii. Building permits are not required to be `signed by property, owners .unless they are performing "their own work
�i personally.
•' Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
IIcommunity or at 1020N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
j these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
r, DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760)
G0) 7 -
O R • GNA RE / ATE
} PROPERTY ADDRESS
PERMIT NUMBER(s)
I ._