0302-005 (PAT)79819 Ambassador Cir
0302-005
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. Dajo%
,U50484 B C 4r, 3J E
Data' o Signature of Contractor}'`
OWNER -BUILDER DECL•ArRATION
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 1•UND Policy No. 494495.2004
(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 Catifomia and agree that i i I should become
subject to the workers' compensation provisions of Section/3700 of the Labor
Code, I shall forthwith comply with these provisidins.
Date: , - -' Applicant LX r'
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 f -•issuance of such
permit, or cessation of work for 180 days will subject rmit to cancellation.
I certify that I have read this4*0p IIII cation 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 f%inspection purfposes. vh
,i
Signature (Owner/Ag nt)
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
vr $7,415,00 16
JOB SITE
APN
ADDRESS 79-8,19 AA1ft;V!;AWH =CUF
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CO]WrRUC17101a
79 AA -Ut Q 0,R
74691 wW=W!?I.GI.. R,C Aro
Lh QU. A. CA 92253
THOUSAND PAINS CA 92276
USE OF PERMIT
PAnO
330 SF.ALUMA.IN001)1.A T I'IC;f? PATIO C.0 rVER.
PO'!RG"10PA,VO 550.00 $F+'
' 1rIA.ylAU'D COST Off' , 1 JWr_R Ple170K
yy q; a ;7 , y,y y
CQ1~ 8wf3t`d CTI0X_ FEE 101«000•418•{3C3t3 $49,00
NECKAN [CAL L FU 101-000.421-000
STROVO MOTION FEE - RVWD 101-000-241-0W
e
D
FEB 0 3 2003
CITY OF LA UINTA
FINANCEP Y.
0TJT3•.T47'1'ALCOAiRfRUCTION KIM PL44? CHl31.x
599.73
'
l !!!illi !illi 111 !illi illi 17
IE
RECEIPT
DATE
r
BYE ..
DATE F!PALED
INSPECTOR
14ks
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Glade
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 8 Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
WaOr Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sher Pans
O.K. for Finish Plaster
Sew_.• 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:
F-IM111 18
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:
79-819 Ambassador Circle, Lot 16, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTE D THICKNESS: R-13
G
IN
COMMUNITIES LICENSE #
E: !/
'CO COMPANY LICENSE # 632072
BY: TITLE: . 'ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
i";
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -411
Prdject Title
J . _f t—K ,ytily Fk=D WAV-INGTI 9 JU IIJTA
Project Address
Joy R0&10sod 15
Builder Contact Telephone
K I f- H,1, 2 S ,' 4 • , 2 o d- 4-
H E R.&R at
Teleph
&e 'i ing S natureDate
Firm: DF- SE 2T E ki 'if -P -v I c -E-5
Street Address: j C) Ye 6'
Copies to: Builder, HERS Provider
OL
::FE5 4-/o ff
Dat—
S Li
BuilderName
EL A tJ S x S
PlanPlan- ber
P-0 Li F
Sample Group Number
La T # Ito `19.819 Q n EinSsapee,
Sample House Number
HERS Provider: L°, 1-, 9, S.
City/State/Zip: K J&Ho iKA Gt , c rA. °iu7a
HERS RATER COMPLIANCE STATEMENT
The house was: ID Tested U' 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.
❑ :.IINIMUM 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 no, 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%or less)
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Measured
values
Yes is a pass
❑ MINIMUM 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
Compliance Forms
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
August 2001
❑ a
Pass Fail
❑ ❑
Pass Fail
❑ ❑
Pass Fail
A-16