BMCH2017-0116LICENSED CONTRACTOR'S 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.Professions Code,
and my License is in full force and effect.
License Class: C20. C36 License No.: 686310
Date: ' r'1 Contractor: �fL
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
( ) 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the 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 or she did not build or improve for the purpose of sale.).
(� I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(i I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
7
Lender's Name:
Lender's Address:
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 and policy number are:
Carrier: INSURANCE COMPANY OF THE WEST Policy Number: WSD5031658
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: '4 n Applicant: C�
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Date:q 14 1 12_Signature(Applicant orAgent):—S�C�—
C`
].f{/ Q�i
VOICE (760) 777-7125
78=495 CALLE TAMPICO
� 0 U -`
FAX (760) 777-7011
FAX
LA QUINTA, CALIFORNIA 92253
DESIGN &DEVELOPMENT DEPARTMENT
777-7153
'1
BUILDING PERMIT
DaFte: 4/4/2017
Application Number:
BMCH2O17-0116
Owner: w
Property Address:
APN:
80709 OAK TREE
775082037
RICK JOHNS I-
��)
Application Description:
JACKSON / HVAC CHANGE
OUT - 18SEER/80AFUE SPLIT SYSTEM
off9
80709 OAK E
LA QUINTA, CA 92253
o
Property Zoning:
Q
r— z
Application Valuation:
$15,737.00
LLJN
tet+ g �O
Applicant:
Contractor: C U w
IE INC
HARRISON EN ISES I NA!flBA iiV L AIR
31225 LA BAYA
31170 RESERVE D V Q V
WESTLAKE VILLAGE, CA 91362
Z
THOUSAND PALMS, CA 92276 Q
(760)343-7488® C
Llc. No.: 68631i= Q
LICENSED CONTRACTOR'S 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.Professions Code,
and my License is in full force and effect.
License Class: C20. C36 License No.: 686310
Date: ' r'1 Contractor: �fL
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
( ) 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the 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 or she did not build or improve for the purpose of sale.).
(� I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(i I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
7
Lender's Name:
Lender's Address:
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 and policy number are:
Carrier: INSURANCE COMPANY OF THE WEST Policy Number: WSD5031658
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: '4 n Applicant: C�
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
Date:q 14 1 12_Signature(Applicant orAgent):—S�C�—
Date: 4/4/2017
Application Number: BMCH2O17-0116 Owner:
Property Address: 80709 OAK TREE RICK JOHNSON
APN: 775082037 80709 OAK TREE
Application Description: JACKSON/ HVAC CHANGE OUT - 18SEER/80AFUE SPLIT SYSTEM LA QUINTA, CA 92253
Property Zoning:
Application Valuation: $15,737.00
Applicant: Contractor:
IE INC HARRISON ENTERPRISES INC DBA GENERAL AIR
31225 LA BAYA 31170 RESERVE DRIVE' r
WESTLAKE VILLAGE, CA 91362 THOUSAND PALMS, CA 92276
(760)343-7488
Llc. No.: 686310
Detail: HVAC CHANGE OUT - 18SEER/80AFUE SPLIT SYSTEM..CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION. 2016
CALIFORNIA BUILDING CODES.
J
FINANCIAL •• •
DESCRIPTION ACCOUNT QTY AMOUNT
BSAS SB1473 FEE 101-0000-20306 0 $1.00
Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT- SPLIT -SYSTEM
101-0000-42402
0
$76.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$38.00
Total Paid for CHANGEOUT: $114.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27
Total Paid for PERMIT ISSUANCE: $96.27
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
$5.00
Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00
Bin #
Permit 4
Project Address: �b7� 00.k1ree—
City of. La QUill is
Building U Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-70 U
Building Permit Application and Tracking Sheet
Owner's Name: ;mak J
A. P. Number:
Address: g0 7o q C>ak Ce
Legal Description:
City, ST, Zip: LcV �� a CA Q
Contractor: ,r -
Tele hone:'ZSO-g9'i- (?CO I
Address: 311-70
Project Description: c� c�ce -4 oh G CO i I
City, ST, Zip: atncl 4vnc
Ck Z7Z-7(o
9O occ>►�,TV, vrv��c�.
TeleP h o nc !c0-
3 4
State Lie. # : 0$(031®
City Lie.
Arch.,'Engr., Designer:
Address:
City, ST, Zip:
Telephone:
trueton Occupancy:
Construction Type:
s
State #.
tat Ltc
• Alter Repair Dem
oProJectnPe circle one), New Add'n
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project: 4 IS 737.00
APPLICANT: DO NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance.
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Dced
Plans picked up
S.M.I.
II.O.A. Approval
Plans resubmitted
Grading
IN ROUSE:-
'rd Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fees
STATE OF CALIFORNIA
ALTERATIONS - HVAC
ire% j�
CEC-CFIR-ALT-04-E Revised 01/16 CALIFORNIA ENERGY COMMISSION "%ft -W
CERTIFICATE OF COMPLIANCE CF1R-ALT-04-E
Alterations - HVAC CZ 2, and 8-15 (Page 1 of 1)
Site Address:
Enforcement Agency:
Date Prepared:
Permit#:
$0709 �A�
C n>01 Y-,4,--
'-(1 4117
Equipment Type
Equipment Efficiency
New ucting or Lineset:
Required R -value
Conditioned Z
Floor Area (ft)
Thermostat
❑ Packaged
j8(Evaporator CoilAFUE
COP
❑ R-6 (CZ 1-10, 12&13) Ducts
Served by system
XSetback
System
Split System
XCondensing Unit
❑ Compressor
❑ R-8' (CZ 11, 14-16) Ducts
1835 ft'
(If not already
SEER
HSPF
❑ a R-2.8 Lineset"
present, must
❑ Mini Split
❑ Lineset
be installed)
X Furnace
❑ TXV
EER
HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this
form is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site.
1. HVAC Changeout/Repair Required Compliance Documents to be left on site for Final:
All Equipment, CF1R-ALT-02-E
Condenser Unit, Evaporator Coil, CF2R-MCH-01-E, MCH -20-H, MCH -(23 or 24)'-H, MCH -25-H'
Compressor, TXV, Lineset, CF3R-MCH-20-H, MCH -(23 or 24)-H', MCH -25-H'
Air Handler/Furnace' (Can include new ducting)
Installer Requirement: Duct leakage (5 15%, or <_10%to outside, or seal all accessible leaks), Air Flow z 300 CFM/ton, Refrigerant Charge.
Exempted from duct leakage testing if:
❑ 1. Duct system registered with HERS provider as previously sealed, or ❑ 2. There is less than 40 linear feet of duct in unconditioned space, or
❑ 3. Existing duct systems are constructed, insulated or sealed with asbestos (list manufacture date of building
❑ 2. New HVAC System Required Compliance Documents to be left on site for Final:
All new equipment and All New Ducts' CF1R-ALT-02-E
including Mini Split CF2R-MCH-01-E, MCH -20-H, MCH -22-H, MCH -(23 or 24)-H', MCH -25-H'
CF3R-MCH-20-H, MCH -22-H, MCH -(23 or 24)-H', MCH -25-H'
Mini Splits require CF1R-ALT-02-E, CF2R-MCH-01-E, and (CF2R-CF3R) MCH -25-H
Installer Requirement: Duct leakage < 5%, Fan Efficacy (0.58W/CFM), Air Flow z 350 CFM/ton (or alternative), Refrigerant Charge
113. All New Ducts with Replacement Required Compliance Documents to be left on site for Final:
All New Ducts' and one or more of the following CF1R-ALT-02-E
replaced: Condenser Unit, Evaporator Coil, CF2R-MCH-01-E, MCH -20-H, MCH -(23 or 24)-H, MCH -25-H
Compressor, TXV, Lineset, Furnace' CF3R-MCH-20-H, MCH -(23 or 24)-H, MCH -25-H
Installer Requirement: Duct leakage < 5%, Air Flow >_ 350 CFM/ton (or alternative), Refrigerant Charge
Exempted from duct leakage testing if: ❑ 1. Existing duct systems are constructed, insulated or sealed with asbestos
❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final:
New ducting but less than All New Ducts' CF111-ALT-02-E, CF2R-MCH-20-H, CF3R-MCH-20-H
Installer Required to: Duct leakage (5 15% or, 1510% to outside or, or seal all accessible leaks)
❑ EXCEPTION: Existing duct systems constructed, insulated or sealed with asbestos.
'All new ducting requires R-8 insulation when more than 40 ft installed in CZs 11 & 14-16 and R-6 in CZs 1-10, 12 &13, and R-6 insulation when less
than 40 ft installed. This includes in walls, between floors etc.
' Heating only systems and Air Handler/Furnace changes do not require Air Flow MCH -(23 or 24), or Refrigerant Charge verification MCH -25
' All New Ducts is when at least 75%of the duct system is new duct material, and up to 25%may consist of reused parts from the dwelling unit's
existing duct system (e.g., registers, grilles, boots, air handler, coil, plenums, duct material)
" R-2.8 (1" thick insulation) for linesets 1" and less.
Contractor (Documentation Author's /Responsible Designer's Declaration Statement)
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the information on this document.
3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the
requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR).
4. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or
system design identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the CCR.
5. The building design features or system design features identified on this Certificate of Compliance are consistent with the information
provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement
agency for approval with this building permit application.
Re onsible Desig . Name:
R nsible Desi Si natures
Da
a S' ned:
License:
r
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'i
4t 11
6310
Company: n \
Address:City/State/zip:
31k -7D ��se
\
(BOJ t70.�•Y.s Q LZ
Phone:
�to0-3�i3-7y�€
era) vC lA�.o1��b
G
o�v.�
For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300