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9512-100 (MISC)LICENSED CONTRACTOR DECLARATION I hereby affirm 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 Signatureof Contractor OWNER -BUILDER DECLARATION I hereby affirm 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). O F as owner of the property, am exclusively contracting i�licenssed :o' �,+ contractors to construct the project (Sec. 7044 Business & Professionals Code). O I am exempt under Section B&P C for fts roasbn_s Date Signature of Owner ism :�'",�. Cr f• y 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 /,1I ;" "A I k -- Policy No. (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 Section 37004 the Labor Code, I shall forthwith comply with those provisions. Date: Applicant Warning: Failure to secure Workers' Compensation ,o,�verage is unlawful and shall subject an employer to criminal penalties and Eivillfi es 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 application agrees to, & shall, indemnify & hold harmless the City of Indian Wells, 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 11correct. I agree to comply with all City, and State lmvv,.re)ating to the building ,,construction, and hereby authorize representatives oM!s�City to enter upon the 1 above-mentioned property for inspection pyrposes Signature (Owner/Agent) / .!; i" 'j Date ALC " _BUILDING PERMIT FERMITal�yjt-;(�q� DATE r f " VALUATION d7ay5vrrrt LOT TRACT JOB SITE ADDRESS 44-105 V.IR.LEI A APN 604-14"o OWNER CONTRACTOR OW N1%E M1.111.11IF11 DAVID E & PHYLLIS PATRIQUIN 44183'4ILL07A DR LA QUIN'1'A CA 92253 C'I L4 DESIGNER/ENGINEER USE OF PERMIT;LECEr IECI t/PL.t M13 CQfv1B1NA '1U UA1toWE, ENCLOSURE TO C:0I401 Y`10NFI) SPACE. FEE DESCRIPTION FEES CON:i'12 IL T Ai 401 4T 7634.00 I'S 0STii'1'IAT.i<•:�:D COST O CONSTRUCTION 7,634M xx,, tlpp* y i, !L, C �,yp�y � ��f,MMI .9C' EE S�Ii.E.��Y. AR MAN C'E3ECK FU 101 -OW -439-318 111164.15 C QNK7"RUC °l 10N FEE 141.0m, _1118-wo 1599.00 ELECT -R r AL FEE 1Dt-000.420-000 S2176 S7't)Nc) MGvm 1-'a d RY-liff► IM -000-241-000 8,76 1N V1?;;7"10KI71014 KA. 101-000-423-000 $99-00 ` '%-�U33.TMAL CON STRUC"`I' O 1 AND ALA`! CHECK $285 81 �� LENS PRF-PAiD 1TES $0.00 ©-TO'[AL PERMIT T hal:-S DUE NOW 520.81 ,QS RECEIPT DATES f BY DATE RNALED INSPECTOR 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 I 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: Q o m- ate-► 2 D= 7r � Z A TN . 7 L �Cl!N 1 b. Z a �r Cy Q o m- ate-► 2 D= 7r � Z A . 7 L �Cl!N 1 b. Z �r Cy 4,,T�.t Q o m- ate-► 2 D= 7r � Z A . 7 L b. Z Ri ca a a7 Com fiance: Residential (Daae or 2') CF -'1 R j( 7A oject o(ect Addreas/� r - - Buddtng Permit a Plan Check Date ocumentatlon Author Telephone Field Check / .Date �mpliance Method (Package, Point System or Computer) Climate Zone cnforeement Agency Use Only IENERAL INFORMATION . tt2 otal Conditioned f=loor Area: j/ 'Single Addition '-uilding Type: Family :Wade one or. morel Multi F Existing -Plus -Addition =ront Orientation: No J Ea South / West / All Orientations (Inpu aeon to degrees and eirde one.) Vumber of Dwelling Units: -loor Construction Type: Slab / aised Floor (circle one or both) BUILDING SHELL INSULATION Construction 3omponent Insulation Assembly LocatiorvComments etc.) Type R -Value LI -Value (attic, to qaraq e, typical, Wall Wall ............. I/�tl/ Al Roof ............ — Roof ............. Floor ......:...... . Floor ............. Slab Edge.... FENESTRATION Shading Devices Fenestration .Area Fenestration Interior Exterior (roller blind. etc.),. (shadescr en, Overhang ' Framing Type etc.) !vas/no) (metal/woodNin I) Orientation (St)LI-Value Front..... (vf 35.b Front.. . ( ) Left ....... ( ) Left ....... Rear ..... ( ) Rear ..... ( ) Right..... ( ) Right..... ( ) Skylight ......, Skylight ....... THERMAL MASS 7-,Certificate*of Compliance: Residential (Page 2 of 2) CF -1 R project Title Date 9 HVAC SYSTEMS Note: Input hyelronic or combined hydmnic data under Water Hearing Systems. except Design Heaong.Load. , Distribution Heating Equipment Minimum Type and Duct or Type. (furnace, neat Efficiency Location Piping Thermostat .dump. etc.) , . (AFUE/HSPF) fductsianic etc) R Value Tvcle Cooling Equipment Minimum Duct Type .(aIirconditioner, Efficiency Location Duct The Configuration, heat pumo. evao. coolinoi (SEER) attic, etc.) R -Value TYpe sola or package) WATER HEATING SYSTEMS Energy Extemal Water Heater Rated' Tank Factor or Tank Distribution Number Input (kW Capacity Recovery Standby' Insulation Type Tvoe in S stem or Btu/hr) (allons) Effi cienCY Loss %) R -Value x. .1. For small gas storage (rated input S 75.000 Stu/hr)• electric resistance and heat pump water hesters..list Energy Factor. For large gas slu►sge caster haean Ira[ed input 2 75,000 Btu/hr)• list Rated Input• Recovery Efficiency and Standby.Loss. For instantaneous gas wear heaters• list Rated Input and Recovery Efficiency. SPECIAL FEATURES/REMARKS (Add'extra sheets if necessary) COMPLIANCE STATEMENT This certificate of compliance lists the building features and performance specifications needed to comely with Title 24. Parts t and 6, of the California Code of Regulations, "and the administrative regulations to Implement them. This certificate has been signed by the individual lnnffl overall design responsibility. When IN s, 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. Designer or Owner (per Business 6 Professions code) Documentation Author, Name: .�J11/J� / �� ' / �,�G1 ✓�`J Title/Firm: Name: Address: ride/Firm: �C S1 /rP�J 1L LTi, i • Address: Teliphonw. J Telephone: . Lic. a: Is, (date) :(signature) O Enforcement Agency'- Name: gencyName: Title: Agency: ------------- Telephone: . (signaturerstamp) (date) . Revised Januar 1002 The POLICY PERIOD shall begin and end, at the Location of Properly involved, k L L S T A T E. •I N S U_ R A N C E .COMPANY as indicated below (See reverse side for additional policy provisions). )ECLARATIONS ISSUED 11-01-95. 0 67 447313 12710 BEGINS ON'DEC 10, 1` AND CONTINUES UNTIL CANCELLED. DAVID PATRIQUIN 12 01 A.M. STANDARD T: 44185 VILLETA LA QUINTA CA*'92253 v DWELLING IS OF... FRAME CONSTRUCTION AND OCCUPIED BY 1 FAMILY HOME SAVINGS OF AMERICA FSB LOAN NO. ITS SUCCESSORS &/OR.ASSIGNS 01297482 P 0 BOX.7075 PASADENA CA•91109. The following coverages and limits of liability apply as shown below. If the word "amended" followed by a date appears above, the insurance applies only from that date. POLICY COVERAGES AND•LIMITS OF LIABILITY A -DWELLIN'G °PROTECTION;- WITH' EXTENDED LIMITS. $256,01 B OTHER STRUCTURES PROTECTION 25,61' C PERSONAL•PROPERTY'PROTECTION-REIMBURSEMENT�PROV. 192,01 ADDITIONAL LIVING•EXPENSE `. UP -TO 12 MONTF X FAMILY LIABILITY, EACH OCCURRENCE 300,01 Y•GUEST•MEDICAL PAYMENTS EACH PERSON s BC BUILDING CODES"f REFER TO POLI( 'WC WORKERS' COMPENSATION - PRIVATE RESIDENCE EMPLOYEE( INCLUDED, IN TOTAL -S) OCCASIONAL.CLASS'. POLICY PREMIUM LOSS DEDUCTIBLES) APPLICABLE. $1000 ALL PERIL DEDUCTIBLE APPLIES TO COVERAGE(S)A,B•& C SCHEDULED PERSONAL,PROPERTY JEWELRY `a SUBJECT TO THE'FOLLOWING FORMS AND ENDORSEMENTS AP425 ALLSTATE AMENDMENT OF POLICY PROVISIONS AP28 CALIFORNIA'AMENDATORY ENDORSEMENT AP337 '°'DELUXE PLUS HOMEOWNERS POLICY ... et AP4;L 45 BLDG STRUCTURE REIMBURSEMENT EXTENDEDIMITS AU1530 SCHEDULED PERSONAL PROPERTY AU319 _ LENDERS LOSS,PAYABLE••' 't r • r. a' The POLICY PERIOD shall begin and end, at the Location of Properly involved, k L L S T A T E. •I N S U_ R A N C E .COMPANY as indicated below (See reverse side for additional policy provisions). )ECLARATIONS ISSUED 11-01-95. 0 67 447313 12710 BEGINS ON'DEC 10, 1` AND CONTINUES UNTIL CANCELLED. DAVID PATRIQUIN 12 01 A.M. STANDARD T: 44185 VILLETA LA QUINTA CA*'92253 v DWELLING IS OF... FRAME CONSTRUCTION AND OCCUPIED BY 1 FAMILY HOME SAVINGS OF AMERICA FSB LOAN NO. ITS SUCCESSORS &/OR.ASSIGNS 01297482 P 0 BOX.7075 PASADENA CA•91109. The following coverages and limits of liability apply as shown below. If the word "amended" followed by a date appears above, the insurance applies only from that date. POLICY COVERAGES AND•LIMITS OF LIABILITY A -DWELLIN'G °PROTECTION;- WITH' EXTENDED LIMITS. $256,01 B OTHER STRUCTURES PROTECTION 25,61' C PERSONAL•PROPERTY'PROTECTION-REIMBURSEMENT�PROV. 192,01 ADDITIONAL LIVING•EXPENSE `. UP -TO 12 MONTF X FAMILY LIABILITY, EACH OCCURRENCE 300,01 Y•GUEST•MEDICAL PAYMENTS EACH PERSON 1101 BC BUILDING CODES"f REFER TO POLI( 'WC WORKERS' COMPENSATION - PRIVATE RESIDENCE EMPLOYEE( INCLUDED, IN TOTAL -S) OCCASIONAL.CLASS'. POLICY PREMIUM LOSS DEDUCTIBLES) APPLICABLE. $1000 ALL PERIL DEDUCTIBLE APPLIES TO COVERAGE(S)A,B•& C SCHEDULED PERSONAL,PROPERTY JEWELRY 15,0[ SUBJECT TO THE'FOLLOWING FORMS AND ENDORSEMENTS AP425 ALLSTATE AMENDMENT OF POLICY PROVISIONS AP28 CALIFORNIA'AMENDATORY ENDORSEMENT AP337 '°'DELUXE PLUS HOMEOWNERS POLICY AU277-2' STANDARD FIRE POLICY, PROVISIONS AP4;L 45 BLDG STRUCTURE REIMBURSEMENT EXTENDEDIMITS AU1530 SCHEDULED PERSONAL PROPERTY AU319 _ LENDERS LOSS,PAYABLE••'