0203-370 (SFD)79791 Ambassador Cir
0203-370
LICENSED CONTRACTOR DECLARATION
I hereby affirmomder penalty of perjury that I am licensed under provisions of
Chaptef'9 (c6m4iencing 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
714180 11 10431 fix"
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:
Carrier ,DSN EA01.g r1gS, Policy No. 'SWC= :,44068.03
(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: f
Date: Y ' i Applicant ~r „! ?, . % j :'i v
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 7
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.
-'x;, , c 1UL471r . Date e -,,Z
Signature (Owner/Agent)
BUILDING PERMIT PERMIT#
02,03-3,70
DATE VALUATION SM 0-0 M LOT ;,v TRACT
JOB SITE
ADDRESS 79-1.93, A.MDAASSA1 OR CUCLF.
APN
Cria' id-0722-003
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CEir3°17A?it't°''C'iwb:ulCUN4rI NI7(`.
C;ENTt3RY IC Crir 37 .C17:@ui3`;23 1rx l f
.15 3 5 SO.. "D° 9=011T, VrE #200
15351.10. To 'hMMET, MT, 4700
raw DEAWAX WX1\70 CA 92409
SANDEMWARD010 CA 92408
(909)381-x,007 C—MA 2120
USE OF PERMIT
M01X F LY DW=_1 JI9aG
S'P'15 - LOT 14 V;i..,AN 3C:1tW. PERA-11T DOW WOT INCLUDE O'LOC,
WALL,'- P001, SPA OR DWSWAY .Ak':i'i'OACH, IS%PLAN CURCK FRE '
REDUCTION FOR MULTIPLE ISSUANCE OF AMK PLAN TYPZ
TRACT C 0143TR11Cr'TION 3F
PO:RCHM. TIO 91.00 5.1fi
0ARA,OWCARPORT 418.00 SF
EM MTED COV OF L^£3M.Q'T UC17a;?N
:€401070160
P + lea 'T .E i"7s 1 ...rt1► '. '
CONSTRUCTION M 101-000-418-000 $653,50
PLAN CHECK T+'EE: 101-006439.3118 $136.02
MEC:ITANIC+AI..,R 101-,(M-421.000 MOM
ELECTRICAL. NVY, 101.1000420-00:) $117. M
PL1JMI1•l9 0 FFX 1011-000.414-000 a13ttA
STRONG MMION FEZ - RE -SID 101 X000-2831 ui:i) X61 L+.31
OPIADING F9113 101-000-423-000
1DOVNLOPM IMPACT PEE f1,90+go
i
M •
T3is-TkY. rRucrfolff AND PI -011T CIVICK
,0?
$3,034,0?
.€ 6.4 3` `PtRE-P= F =
$0100.
L 00
M
7 Y9
!J 5 {: 1 .iA179i M l +Fwaf F M1b 2'+ NOW
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C17YOFLA(uI A f
-
OINANCEDEPT. 1
111111111111111 1111111111 0$
RECEIPT
DATE
BY.,;,%
DATE FINALED
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 pZ
Compressor
Insulation p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall insulation
Condensate Lines
Party Wall Firewall
Exterior Lath — —g—
Drywall
Drywall - Int. Lath 7
_
Final r G- oZ
BLOCKWALL b ROVALS-'
Final
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 . / 7 -
Heater Final
Water PipingPlumbing
Plumbing Top Out
Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection —> 2/ 57
Encapsulation
Gas Piping
Gas Test ® e f37. 0 Z 5%
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 9
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
3
* /, •, tet.
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
79-791 AMBASSADOR CIRCLE
Bldg. Permit No.: 0203-370
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY CROWELL COMM.,
Building Official
Address: 1535 SO. "D" STREET #200
City: SAN BERNARDINO, CA 92408
By: STEVE TRAXEL
Date: 12-09-2002
POST IN A CONSPICUOUS PLACE
11113101 09 -
IE
- " 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:
79-791 Ambassador Circle, Lot 14, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENERAL CONTRACTOR: CENTURY CROWELL COMMUNITIES LICENSE # ?,(ell >
BY: TITLE:
P, . GON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
BY: TITLE: -ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
1 CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
Joy 90610!5,0d -)722-3 150
Builder Contact Telephone
K l e— H,,, 2 D r Iz." d (76vl S/,4, 9 n
HER ate Telephone
.CN2l= G/3Z 0Z 1VZW6-
Mtih ink Signature Date
Firm:( ESE2T l. EiZ ( R /Ic°_E`5
Street Address: C o. F—LbY, o2 l
Copies to: Builder, HERS Provider
--FF5-Tc o rI/4/off
Date — --I
6-1=-: :lLi
Builder Name
ELA,d 3e -
Plan Number
G 20 Ll P `Z
Sample Group Number
l.o T 4:'-- 14 '74- 79 ! Am csAssAaw z
Sample House Number
HERS Provider: 6, H -E • E, R, s.
Ciry/State/Zip: A-KIS& l il\ t, , °A,Qj2Z7o
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested IR/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 flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _
Check Box for Pass or Fail (Pass=6%o or less)
❑ THERMOSTATIC EXPANSION VALVE (TX
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Measured
values
Yes is a pass
❑ N11N'IMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
❑ 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.
'- ❑ Yes ❑ No TXV is installed or Fan now has been verified. If no TXV,
verified fan flow matches design from CF - IR.
Measured Fan Flow =
Yes for both I and 2 is a Pass
Pass
Pass
El
Fail
Fail
❑ ❑
Pass Fail
Compliance Forms August 2001 A-16