9608-039 (RER)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.
Licenseh j 136 81c. Class Exp. Datea()Ji
,ff I(�' =
VDate Signature of Contractor
Y
OWNER -BUILDER DECLARATIOV
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 ,
• c.
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\6Rhd_1T;gl3or Code, for the performance of the'W6rk±,f6r,8which 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).
( ) 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 shtuld become
subject to the workers' compensation pr visions of Section 3740 `tithej Labor
Code, I shall forthwith comply with those provisions.
VDate: tir-W Applicant 1-1.+ ) —? ��{1.. ,.
V
Warning: Failure to secure Workers' Competition 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 fdr inspection purpose .
VSig at e�"•��'
(Owner/Agent) 1 Date '.
v. Y. Y.
'
,,,,„,BUILDINGPER�VIIT ,' PERMITj�#ht�m��p CONTROLN
3853
DATE VALUATION LOT TRACT
0,10
JOB SITE X3^1•-vvrw E➢. ._ r.:h .
APN ' ••—� ..—e .
ADDRESS.
OWNER
�i�1f,I UMM B & SUSAN DAGt•3f'.i
CONTRACTOR / DESIGNER / ENGINEER r
f1prr CrT2.1'T':� CIONI +'�{ItJ't...1�i.C)w
34604 INVERNESS WA
54705 A.E.. c.AtucANZA
LA Q STN A. CA: ' 92253
LA. QUTN'T'A CA 92253
(
t EtL# 296.8
USE OF PERMIT
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Wro:tsi4lOfi�r�l�rE
00-'POTAL CONS"3't UCITON AND PLM C:t11?rK,
LESS i'R E-PA10 F.1;ES
WOO
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•T A. IO�isQ� -
R CEIQT�
DATE / (
BY (” `
D, FINALED `
INSPECTOR i
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
POOLS - SPAS
BLOCKWALL PPROVALS
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
Gas Test
Appliances
Final
COMMENTS:
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)
COACHELLA VALLEY UNIFIED SCHOOL DISTRICT
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
Project Name:
Project Address: 64-604 Inverness Way, La Quinta, Ca 92253
Project Owner's Name: William B. & Susan Dalbey Phone No.:
Project Description: Residential Remodel
Building Type (Check one): /-'� Residential XX (Include No. of Dwellings)
Tract No.: Lot No.:
(If tract, attach Schedule "A" of all lots by tract, square footage for each lot and total.)
Assessor's Parcel No.: 769 451 001
(If Schedule "A" is used show Assessor's Parcel No. for each lot if one exists or Assessor's Parcel No. for parcels before subdivided.)
Total square feet of Building Area: --72 Sg . Ft . --
Certification of Applicant/Owners. The person signing certifies that the above information is correct and makes
this statement under penalty of perjury and further represents that he/she is authorized to sign on behalf of the
owner/developer.
Dated: �I �o Signature:
City/County Certification:
(Signature) Optional
(Title)
*RRRRR**RRRRRRRRRRRRRRRRRRRRRRRRRRR*R**RRRRRRRR*RRRRRRRRRRRRRRRRRRRRRRRRRRRRR*RRRRRRRRRRRRRR
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WELL BE
SATIS�DJN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE):
Gov. Code v. Code Project Agreement Existing Not subject to fee
53080/65995 , 65970 Approval prior to 1/1/87 requirement.
Total Number of Sq./Ft. 72
Amount per Sq/Ft. $ -0
Amount Collected $ -
School District. Official
Foch "Tut" Pensis
Date: August 13, 1996
Note: Pursuant to AB -181
any room additions, remodels and
modifications of 500 sq..ft: nr less
are exempt from dev. fees.
Title: Asst. Superintendent, Administrative Serv.
Phone: (619) 399-5137. Eat. 235
Note: AB 2926 and SB 201 fees are capped at $1.84 per square foot for all residential construction, and at $0.30
per square foot for commercial/industrial projects.
ni icare of Comcl iance: Residen'toal
. (Page t or 2) LF -1 R
L2 tClimate Zone Enforcement Agency use Only
ampliance Method (Package. Point System or Computed
3ENERAL INFORMATION
otalConditioned Floor Area: IL q2;uilding Type: Single Family `Addition
:heck one or more) Multi -Family Existing -Plus -Addition
=ront Orientation: North / East / South / West / All Orientations
(Input onentauon to degrees and circle one.)
Vumber of Dwelling Units'.
loor Construction Type: lab aised Floor (circle one or both)
BUILDING SHELL INSULATION
Construction
3omponent Insulation Assembly LocatioNComments
rype R -Value LI -Value (attic, to garage, typical, etc.)
Wall.. .. ..
Wall ..............
RoofX.(,n..
Roof .............
Floor...........:.
Floor .............
Slab Edge ....
FENESTRATION Shading Devices
Fenestration Area Fenestration Interior Exterior Overhang Framing Type
Orientation (sf) U -Value (roller blind. etc.) (shadescreen. etc.) (yes/nol (metal/woodNinyl)
Front.....
Front..... ( )
Left .......
Left ....... ( .)
Rear ..... ( ) \
Rear .....
Right.....
Right..... ( ) \
Skylight
THERMAL MASS
Type/Covering Area Thickness
(slab/exposed the etc) (sf) (inches) Location/Description (kitchen. bath, etc.)
/.t
J 7 - ---
Revised January 1992
Certificate of Compliance: Residential
/13--- n ,-s n% ^r . e-%
HVAC SYSTEMS
External
Tank
Note: Input hyaronic or combined hydronic data under
Water Heating Systems, except Design Heating Load.
Heating Equipment Minimum
TIstribution -
YPe and Duct or
Type (furnace, heat Efficiency
Location Piping Thermostat
Pump. etc.) (AFUE/HSPF)
(ducts/attic, etc.) R -Value TYpe
Cooling Equipment Minimum
Type (air conditioner, Efficiency
heat purno. evao..cooli a) (SEER)
`+� C -e
WATER HEATING SYSTEMS
Water Heater Distribution
Duct
Location Duct
(attic, etc.) R -Value
Number
in Syste
Thermostat Configuration
Type (split or pack;
Energy
Rated' Tank Factor or
External
Tank
Input (kW Capacity Recovery ' Standby'-
Insulation
or Btu/hr) (gallons) Efficiency Loss (%)
R -Value
1. For amall-gas storage (rated input!S 75,000 Btu/hr), electric resistance and heat pump water heaters, list Energy Factor.
For large gas storage water heaters Irated input a 15.000 Btu/hr), li
For instantaneous gas water hasten, st Rated Input, Recovery Efficiency and Standby Loss.
list Rated InputEffiEfficiency and Recovery Efficiency.
SPECIAL FEATURES/REMARKS (Add extra sheets if necessary)
COMPLIANCE STATEMENT
This certificate of compliance Ilsts 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 cenlficate of compliance Is submitted for a single building plan to be builtin
orientations, any shading feature that Is varied is indicated in the Special Feaiures/Remarks section. multiple
Designer OeQWffft4W9usineas &. Professions Code)
Name:] —
Tide/Firm:
Address:
Telephone:
Lic. r:
(s nature)
`(dam) �P
Enforcement Agency.
Name:
Title:
Agency:
Telephone:
(Signatureistarn (date)
Revised January 1992
Documentation Author
Name
effN-3-RME