0209-100 (RPL)79760 Ambassador Cir
0209-100
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
656128 C53 I -Tic C-8 I0,r ./2C
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:
( ) 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:
Carver STATE G17MI°!.%t4?AT] Policy No. 046000610.01
(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 of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
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, 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 for inspection purposes.
Signature (Owner/Agent) Date
• BUILDING PERMIT PERMIT# Y
'''
DATE VALUATION LOT r'
TRACTJOB
SITE
ADDRESS ! "'7 As ftW li kal. / n6:+
APN ,- -,
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CENTE7Ry MO 'E . CC)kr MMITTES
0AMlltNIAIyC7 M SPAS (TOP?►l AN CO
1,535 SO. "I)" UTR W=MM #200
86.100 ;fZ1 1W,,N'F7'F.S4
SAN BM—T.r+RIANO CA 92,408
C OAC:aMa.rA. CA. 92236
USE OF PERMIT
POOL AND/OR, UIP..
POOC.I°SP A. AIJARhQ4MARRITIRS Rkie4:1 L BE IN PLACE AT PR&PI.AS'lER.
,TNS11E,:T.(0 F. FA)t.JiPI+IIENT MCLOSURE NOT TrrC.' UT*17.1
POOLANIXOR SPA oDmoq LO
E:V,I71i>1 AM) COST OF COP7STIRI}'C113t,?sq
17,009.00
'PIM iW 76'Iia1: StrMTKAR +
P (A -M K I'M 101..000.439.318 5117.00
CONSTRUCTION FEE, 101-,000-41..8-000 lbIgo. Do
M&C1.0MCAL,ri;P:. FOOL 101-000.421.000 $24.00
MIXTRICs*.LFEB. -POOL, 101-0,00-4W,--000 $45.00
T'PutTMB-1110 FER, ..11000, 101.00u7a'I19.000 M.00
SUB-TOTAT, COMMAWCTIT 09 AM PLAX 0FIECK
$393.00
LES 1'Kr!,-. A1..D M3,
$0.00
".rOiTI*L FEES DUE NOW
IIIIIII VIII III VIII IIII 72
IE
s
/
RECEIPT
DATE
BY
DATg FINALED
INSPECTOR
V.
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 APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain'`(""'
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
Gas Test
Electric
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)
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
656128 053 3 C C-8 3 W 1 iW
I s
Date • !l . Signature of Contracto•,r —!
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 COMPENSAT1 Policy No. 4460006160.01
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the'w ork 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 provisigns
Date: Applicants . r`
'
Warning: Failure to secure Workers'Compens ion 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 rtinspection purposes.
Signature (Owner/Agent) ( ' + -off Date 0 Op—
_ ' +w' PERMIT #
- BUILDING PERMIT
DATE VALUATION v2 two LOT TRACT
m
rix
JOB SITE
ADDRESS 79— 60 AA 'vMA.FE"•S, 1, OR"—C7R6."YJr
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1.535 SO. '1a 1 zt:F' '1', 9M. 0200
86.1(V AVENUE 4
SAN BIMNAR03NNO CA. 92-108
COACEMMA #24 92236
('mpgo-97,22R, 00355
USE OF PERMIT '
P'00, L' ANlf0R 01-1 A
PIJOWPA. ALA.Kd44s,'Bsat;?.Ft ERS SHALL ISE AN PL CEAT PRt-PLASTER
W'?J1 . '..(v" ION, FQUIPi►61: r3'i %1 ° rbu; iU . ': i 1' MCiktfDED
FOOL ANDIOR. 0 Pad 17,000,00 LIS
We IMAM CQ6.rOff' CONS %€'!3'C710N,-
PW4 CHECK ME 101-000-439-318 5117.09
CONSTFt:tXTILId t°10 101-00"19.000 $180-00
A3E ANICAi,1'"R8...1'OOL 1101-000-421-000 $, ,Oil
=C`•TFL@ A1,PSTW,.-'POO. 101-000-+126-000 3145,0
PisC7i►RB040 M,- POW )01-000419-000 11,`3.00
1 il
CITY OF LAMMINITA-111AT. COA11 :l ITC. 1313 AND MAN`05- 4{C
$393.00
FINANCE DEPT. VEZ,5 FR;-1~MD RRES
$0.00
11111111111111111 73
IE
RECEIPT
DATE
BY
DAT/ FINALED
a
INSPECTOR
kr.
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
steel
POOLS - SPAS
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
47-
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:
t
r . Y.4 IIIIIIII I IIIIIIIIIIIIII 74
H -
INSULATION CERTIFICATE
This is to certify that insulation has been installed in -conformance with the current energy
```regulation, California Administrative Code, Title 24, State of California, in the building located at:
79-760 Ambassador Circle, Lot 11, La Quanta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CONTRACTOR: CENTURY CROWELL COMMUNIT ES LICENSE#
BY: -
TITLE: !
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
BY: TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
sirim7sivi %!/vivivioi>iviv.:•ai..r/s/ 'n%/ir/OArYi7lri,R/.eirid+/.riv/.!:Xaa/.✓i%O/O/d//.':f%4///d%a /A/.rf//Y/O/d/l7lio/B% %.f:!G%n'7I.Y/ J/I/lI/J%J'iB%Y/ /iidiLY !i.!/_%V%1%d"/Jar,
V
11
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
1"'411)J -TI cr I iy /(-""4 N M.
Pr sect Title J II n \✓, 1 f
►J G JLJ I d -TA,
Project Address
J o e F7,061 772- 3 15 8
Builder Contact Telephone
iz 1&- H A R D S/, 4.9 n 2 A -
HER
Telepho
_1A ' 7 -AFC/, -1 freewk#,*mojZ- 1112
r
Cenif. z. SignatureDate
Firm: DFSELZ J -._C JEa5'r Eayic-E
Street Address: i O - Fi x (102 i
Copies to: Builder, HERS Provider
L
I 5 TtE:7 D f 14-/o z-
Date
IJTJ(L`(
BuilderamT r a '--
FLOsd 5xC-
Ian Number
GI 20 LJ P
Sample Group Number
1.o T 4t- 1 I 79• %6D A7BWSA0aP-
Sample House Number
HERS Provider:
Ciry/State/Zip: rA-AIN_Ho P1(FA.' )'1-77o
HERS RATER COMPLIANCE STATEMENT
The house .vas: ❑ Tested I Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply
ith the diagnostic tested compliance requirements as checked on this form.
❑ The installer has provided a copy of CF -6R (Installation Certificate.
❑ Distribution system is fully ducted (i.e., does not use building 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 leaks at duct connections.
❑
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Duct Pressurization Test Results (CFM @ 25 Pa)
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here
If fan now is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _
Check Box for Pass or Fail (Pass.=6% or less)
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ 1'es ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Measured
values
Yes is a pass
❑ ntli\l!11UM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
l ❑ Yes ❑ No ACCA Manual D Design requirements have been met (rater has
verified that actual installation matches values in CF -I R and
design on plan.
ET Yes ❑ No
Compliance Forms
TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -I R.
Measured Fan Flow =
Yes for both I and 2 is a Pass
August 2001
❑ ❑
Pass Fail
❑ ❑
Pass Fail
❑ ❑
Pass Fail
ow