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SFD (0311-053)50475 Los Verdes Way 0311-053 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 Contractor f _ L ? 0 w OWNER -BUILDER DECLARATION- ' ­I hereby affirm under penalty of perjury that I amiexempt 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: ( ) 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 th6 work for which this permit is issued. (I ) 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 MEATY t yy 6 F9 try Policy No. 1f 'Qh ai n 1' « fl N [.c«G.L%RS : 7 M UT LIAL V VYa b .. V{. : ^i cM u i 122 I (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 ` l ,- Warning:i Failure t© secure Workers. Comp6hsationl coJerage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued•as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. (Owner/Agent) I ---We Date 10 BUILDING PERMIT PERMIT# DATE VALUATION LOT D?,t - TRACT p y r+ y ry JOB SITE I APN ADDRESS -•475'L0,5'i'1' ;EvIAS W:kr.It' OWNER CONTRACTOR / DESIGNER / EN INEER TOLL 13:E.R41 INC" 13-1Z I 'IMM'YVAR'D,y . 0 7;3«121 AM) WAR Ni 100 Ppil/I Dt% 'P CA !-2260 PA M DF -91W s: A 5+226{) (160)674 -969 3832 USE OF PERMIT VD, , LOT 107, l:'Zl;''A- rT ID0FA NOT INC'i1,Yft "29l i.3.e:j CZ" Vy %irJ iUS, Pt .rX, VA. LJ} :.9?y.1 V 11? .t E'6=R.C3,A.f.":i3a. 75'iir P1.&3 CHICK f7W' DVX , » I>dULTIPL& MWANCE Ott MhlL", F>E KNt TY*K._: QUOTi OM C OMS -`$'.MICTICiN 2,gov of) St.' PLAN -V.3 sp 0-6 2004 610;W OF CITY C F LA QUIiNTA Fl%lf !.1T MKrKD CsV, r C:ONSMUCTRxi iYCE DEPT. CQRS'!'It"GrCT1117*17, VL kW C:c3fi X FEE MECHANICAL VEX 103 Ah..XM,,?'1.-001) X11 i. t9 F14CC'd 1.°dC`-AI, liar I Cil l -;000-A20-000 P1rli ; cl ' }F Xf - 1t x^'(1i4i'1'4is"tYt1 td 1.t ;t `'aTRO140 MOTICIIN P'}?•I" — PIMSIU 3 01-00CL241-Ot)t) O12,&MI0 3N 3ufl OtiCi t?;3•(900 $1i3Ofi FAM TOTAL PERACT FFE3 .%'L7R Now I4;324 90 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 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 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 A/Pff,OVA S Gas Test Electric Final Waste Lines Heater Final Water Piping _-Mumbing 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: t1l 09/17/2004 00:28 FAX 7149212187 ALLIANCE MECHANICAL 10008 INST /A LLATION CERTIFICATEa 7(Pe I of 13) n CF -6R Site Address Permit Number An installation certificate is requited to be posted at the building site or made available for all appropriate inspections, (The information provided on this forth is tequirtd; however, use of this forts 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). QAC SYS„TLMS: Hearing Equipment Equip. slof Emcleaey. Duet Duo or Hewing Type (pkg• CFC Certified Mfir Nano identical (AFUE, etC)1 London Piping Load Hcada Capacity F_MUM 71 unlace —7 8 output Cooling Equipment Equip, -ac Cetdned Compressor M of Efficiency Duel Cooling T Ype (pkg. Unit Mfr Name and ldmtical (SEER, oa)t L"Id" purl Cooling Load hew, wuw,wl U".l W-6— n._.—_ e..wn .- __._ . . _ . _ Capacity AnrZ oonF 3— —Tii a b 1. > reads greater than or equal lo, I, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, :) equivalent to or mom efficient than that specified in the certificate of compliance (Forte MIR) submitted for compliance with the anergy Efficiency Slandards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for manufactured devi es (1 17 the Appliance Efficiency Regulations or Pact 6), where applicable, ALLIANCE MECHANICAL 1-IVAC Signature, Date Installing Subcontractor (Co. Name) WATER HEATING SYSTEMS OR General Contractor (Co. Name) OR Owner Distribution If Wr- 0 of Reed' Tank Em- External Heeler CEC Certified Mfr Type (Std, culation, Identical Input (kW Volume eiency' Sundb? ImWion Typc Nano & Model Number Fointof.Use) Control T SYMMS Of Wild ( allots) (EF, REl Loa (Ya) R -value' 2 For small gas storage (rated Input or iess than or equd to 73,000 BUM, ehetrlc resivanet end beet pump water heelers list Energy Factor. For targe gas storage water beaters (rawd input orgnuer thm is,000 Btufir). list Recovery Efrieieney, Standby Los; and Ratcd Input. For Instantaneous gas water hewers, list Rteovtxy Efficiency and Rated Input, 3. R-12 external insulation u mandatory for storage water hemcm with as rWgy factor of less flan 0.1g. Faucets At Shower Heads: All faucets and showerheads installed are certified to the Commission, pursuant to Title 24, Pan 6, Section I'] 1, 1, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) equivalent to or more efficient than that specified in the certificate of compliance (Form CF -IR) submitted for compliance with the Energy Efficiency Slandan* for residential buildings; and 3) equipment that mats or excads the appropriate requirements for manufactured devices (from the Appliance Effeleney Regulations or Patz 6), where 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 (t' A-23