SFD (0311-048)50425 Los Verdes Way
0311-048
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
.Date Signature of Contractorr' flt
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).
O 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:
j (). 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
SeHon 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:
Cartier Policy No.
1ABW11kT7 aAUTAll R 231012TI
(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 provision's-of'Section 3700 of the Labor
Code, I shall forthwith comply with'those provi'sions:_""A i
r.
,Date:4.1! -::-.1 -C4 Applicant,;,'-"?:rj
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)4/16 rt' f f I i 17i Date f J• e•
BUILDING PERMIT. PERMT# .
DATE VALUATION LOT' t •e + TRACT
JOB SITE
APN
ADDRESS
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
T.1-123FRIMVTJ'X;M40#300
3. "f V,f.P2.3:0's )0
P.61114 DESER71 CA 91 .12ta0
PALAM. i'M&IO' CA 92260
USE OF PERMIT
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3..10Ti z r. : S"VIVE NOW
RECEIPT
DATE
j _. .i'r.n , r.!i
BY
ice` i,•:f
DATE FINALED
O -
INSPECTOR
-
-
4
INSPECTION RECORD
'µ 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
. .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 a - • a
BLOCKWALL APPROVALS
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 APPROVAS
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
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:
09/17/2004 00:26 FAX 7149212187 ALLIANCE MECHANICAL
INSTALLATION CERTIFICATE
Site Address
[a 003
1 of 13) CF -6R
X041
Permit Number
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required; however, use of this form to provide the information is optional.) After
completion of final inspection, a copy must be provided to the building depaMnent (upon request) and the building owner at
occupancy, per Section 10-103(b).
HVAC SYSTEMS:
ht ng Equipment
Type (pkgl CEC Certified Mfr Name
0 of
idea"
Errtdeocy.
(AFUE, ata)!
Duet
1.001"0
Dao or
Piping
Heating
LAW
Hearing
cipcih
- — 1
Cooling Equipment
Equip. „ C.EC Cestifted Compm w 0 of
Type (pkg. Unit Mfr Name and Idemiral
Efficiency Duet Cooling Cooling
(SBEtt, ete.)t Location Duet Load Cary
ne-t:_ta . .:_ .- -
Arr on — K 1 0 (y
1. t f•F taAmo . . r vO
az D A - 4
roads
-
greater than or equal to.
1, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, 2) equivalent to or room
efficient than that specified in the certificate of compliance (Forst CF -1R) submitted for compliance with the Energy
E,giciency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for
maufactured devices (from App ce E.gieienty Regulations or Part 6), where applicable.
ALLIANCE MECHANICAL HVAC
Stgnatutu, Date installing Subcontractor (Co. Name)
WATER HEATING SYSTEMS: OR General Contractor (Co. Name) OR Owner
DistAution IfReeirro Yof Rued-' Tank ER• Extrmal
Heater CEC Certified Mfr Type (Std, euladonIdmiiT
Input
V ( Imlition
Name doeumer PoipofUse) Control T S m8jWr) (allu) EF RE) Lou (%) R -valuer
2 For small gal storage (rated input of less than or equal to 75.000 Brulhr) electric raduanae and !tear
Pump macer Aea
For large gas -corset water beaters (rated input of 8mur than 75.000 Btwhr), list Recur Erri0 rad lige Energy Factor,
For Instanlaseow ess water beaters, list Rao eAh Swtdpy Loss and Rated Input.
3. R•12 external instilaticn u mandatory for store cWarerEfficiency and Rated Input
ee htatmtets With an energy riketor of less !baa 0.58.
Faucets & Shower Heads:
All faucets and showerheads Installed are certified to the Commission, pursuant to Tide 24, Part 6, Section 111.
1, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) equivalent to
OF more cfTcient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the
Energy Efficiency Standards for residential buildings; and 3) equipment that meets or exceeds the appropriate
requirements for manufactured devices (from to Ap➢ltance Ef ciency Regulations or Part 6), when applicable.
Signature, Date
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Compliance Forms August 2001
' A-23
NOM