SFD (0311-052)50455 Los Verdes Way
0311-051
LICENSED CONTRACTOR DECLARATION
I hen!aby 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
J'r7 i .13 f.
/Date 1 r Signature of Contractor r1'.. • %^"" - _ • t
..^ +„ ) 'i' r tr4•tur. yr M"'1 :w .
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 Policy No.
(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—'+, . e' • , "y? --r----•'^ "
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
' addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) =$s%' ++ } _ t Date r r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0311 TRACT
. . ! ' 33
JOB SITE
APN
ADDRESS
jj !i q, c y} ♦
iI ON V4:.• I A S WAY
a'I.fi' %wi# '•?Iu.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'ADLI,.Y, R07 ERJUNC'.
70,11..L,RW1'i i'. ,RS INC'
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USE OF PERMIT
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Wf IM.1e, 'POOL, ,.<>'A OR URlt!'MAX A.?xPYAE1ACH, 75% RUE . 21_ n
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1'1ril ADIN01TIENI01c0OM!49-000 $1Mi.00
STRO1.140Mls' UMR a F,a IMSIP 101 -MI -°241.000
U[tADlWO FEE M -000 -IM -000
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$4,236"
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PENVIM1' i ► D1T ' ;I OW17
$4,2:16,44
RECEIPT
DATE
BY
DATE FINALED.
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROV
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts -
Slab Grade
Return Air i
Steel
Combustion Air
Roof Deck
—ExhaustFans
O.K. to Wrap ip
Framing—Compressor
Insulation
F.A.U.
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
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 APPROV L
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 Cgnnection
Gas Piping
Encapsulation
r
Gas Test
Appliances
Final
Final ,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring .0,
9_ *-T-- A;;,--
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) — p
COMMENTS:
r
09/17/2004 00:28 FAX 7149212187, ALLIANCE MECHANICAL
0 006
INSTALLATION CERTIFICATE (Page 1 of 13) CF -6R
50 ~ 4E -LLOS VerdeS VV4Xthe
Site Address Permit Number
An installation certificate is required to be posted at the building site or trade available for all appropriate inspections. (The
information provided on this form is ttquired; however, use of this form to provide the information is optional.) After
completion of final inspection, a copy must be provided to the building department (upon request) and the building Owner at
Occupancy, per Section 10.103(b).
HVAC SYS'T'EMS:
Heating Equipmenf .
Equip. 0 of Efficiency. Duct Duet or Heating Hating
Type (pkgt CEC Ceni{ied Mfr Nsme Identical (AFVE, e1o.)t 1.40511109 Piping Load CSE+dh'
Fumaci t 1 .Z- — - a n A, output
S d
Cooling Equipment
Equip, CEC Ccrtiftcd Compressor Y of Effscirmcy Duct Cooling Cooling
Type (pkg. Unit Mir Namc and Identical (SEER etc.) Location Duct toad r,p,dey
6.a --Nu..a-t u ._h . —.--- ti....— •
Ar —r on , r k GE,'t"L w —a"— 57..0 "rWC
1. > reads greater than or equal to.
1, the undersigned, verify that equipment listed above is: 1) is the aotual equipment installed. 2) equivalent to or more
efficient than that specified in the certificate of cOmplimce (Form CF -1R) submitted for compliance with the Energy
Efciencv Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for
manufactured devices (from the Appliance E ►clMy Regulaffont or Part 6), where applicable,
ALLIANCE MECHANICAL HVAC
s
ignaturc, sJatc / Ilrng Subcontractor (Co. Name)
WATER HEATING SYSTEMS: OR General Contractor (Co. Name) OR Owner
Distribution
Heater CEC Ccrtificd Mfr Type (Std
If wr•
euladon,
N of
Idenikat
Rakd,
Input(kw
Tastk
volume
Erri.
eienc?
standby'
ummi
Insulation
T pe ^lame & Model Number Point -or -Use)
Control Type
sygem,
of OWhr)
(Ilom)
(EF, RE)
loan (Vol
R•nluet
2 For small las storaea (rated input of less than or equal to 73.000 titufir), etettrte resistant, and beat pump water hntan. list Energy Faetof,
For large 9,-,' steraee..■(cr heatcrs (raced input of greotatiut 75,000 grugtr), lut Recovory Bf4ialaney, 5utndby Loss and Reed Input,
For Imiantaacous cm water beaten, list Rccovcry Efticimry and Rated input
3. R• 12 eucmal insulation u mandatory for storage Water heigpa with an cKrgy hest of lest Nan o.39.
Faucets & Shower Heads:
All faucets and showerheads installed are certified to the Commission, pursuant to Title 24, Patz 6, Section 11 I.
1, the widersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) equivalent to
or more efficient than that specified in the eatifieate of compliance (Form CF•)R) submitted for compliance with the
Energv Efficiency Standards for residential buildings; and 3) equipment that mars or exceeds the appropriate
requircn•,cnts for manufactured devices (from the Appllanee Efficiency Regulations or Part 6), where applicable.
Signan te, Date
COPY TO: Building Department
HERS Provider Rapplicable)
Building Owner at Occupancy
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
Compliance Forms August 2001
A-23