0106-351 (SFD)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 w� • ���' r
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:
() 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.
OMAN MG -118 INS. A1WC44400-03
(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, /II shall
Z: — all forthwith comply with -those provisions. a l
Date: Cr3ri !r r r 1 APPlicant j,1 . �:a 1.d
dT
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) ,Z + /0 R�~-'-a Date r��'
Y�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
$1156�W.00 24 24197'•1
JOB SITE
ADDRESS
APN
/-tyIy /n, pWyyIM
4 Y�i�pp M091
444,44
f4 spryW6
6134-072-.W6
OWNER
CONTRACTOR / DESIGNER / EN (NEER
A 5 M 1W IISI ,'RT-_ MR ftoo
3 535 iso. "TSR art="um, 0200
CA 92408
SAN DRIWADIDTO CA 97.x1.08
(909)381.60M C�!IB 212,0
USE OF PERMIT
X31+fC.�1�rd:�+.�',.�,5!'.t�"�3E.[:1..J�Y�4
•
FT) .,1,00 24 PLA14 41A • 1PEMMIT 1'3 HS NOT 1'AiC:l.tilDE BLOC 11C WALL,
POOL OR M!.€41'1W.AY APPROACH. 75% C'[.. CHECK M1;. REDUCTION
Ar.k?I?i�i ?01.012 At1UIMPM PLAtd T Pim; a?l1;ib4T'1".Y' )D,
1RAC:Oal:t?UM1014s4so,09'sF
]yRlFyIAfIO 6266 SF
a> Yta�l C A .1zt3 T MAO SW
29MA` "I C: IST QF CfJ%6SM17C'U019
.156,=.10
CONS3x1ttlEw"3ION FER 101 00-41 S-000 snoxo
.ALAN e.S1rECK WE 10x-000-43'9-318 $1 iZ59
MW, RA.114I C A 1, P'E.R 101.000-421-000 MON
Z1.1!,E.." PR%CA1., MIE 10►, -000-420-000 $153,33
F't,'c!M'BING nos, 101.1100 419-0on 1;142,
SA2"kZONO MOTION PF -1 .31D 10,'1-0004M -000 $1166
G:1RAD1140FEE 101-000-42-1-000 $21,00
MV'211091.wt 11 PJACeT PRE$1,�OT.00
�7,T �Y3�c��4�
—_ — — [.7•' i nOw�•✓RV !...aIO £'1J:' D i����d.�7 5..;.[aa::n.,-LY.
CRN
i
$3,316.0 8
$3,316.08
LrSs PRIE-7PIAM P411 '�1
SE100
".TV' FETS DUE NOW
�w�„�lftlii�
JUN 2 5 2001
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ ,H
7 ��/�(
Underground Ducts
Ducts
Slab Grade
_
�
Return Air
Steel
Roof Deck
_
9 6 D_
Combustion Air
Exhaust Fans
O.K. to Wrap/�
_
I
F.A.U.
Framing
` — I
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
_
� — 2� - c�Z �S
Final -
POOLS - SPAS
BLOCKWALL APPROVALS
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
Water Piping
�%—/ s
`' '
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
f f f` �� �S
Encapsulation
Gas Piping
Gas Test
�.7 �.� — p / �J
Appliances
Final
COMMENTS: 13 /4
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
�,—� _dz
Utility Notice (Perm)
.S
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:
44-844 Monticello Avenue, Lot 24, Monticello-Heritage, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: CERTAINTEED THICKNESS: R-38,
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
5
GENERAL CONTRACTOR: CENTURY CROWELL COMMUNITIES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY. LICENSE # 632072
BY: TITLE: .ADMINISTRATIVE ASSISTANT. DATE: 12/12/2002
Jan 29 OE 11:37a Richard Simpson 661 947-6889
INSTALLATION C1ERTITICATE (Page 3 of 8)
Site Addma4 y Mon►T/C ll o A T Permits Number
Au,
P 67- DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE RE
Pressurisation 'feel Results (CFM (a` 25 PA)
Tad i cakags (CFM)
Fan flow
If Fan Flow is Caloulated as 4110 cllao/ton x number of toav, or as 21.7.x I loatiog Capacity
in Thouaanda of UtAr, ontvr calottlatot valuo hero _
If Pan flow is mcrosurcd, cater measured value hurt J Lxt)
Loakago Fraction ='Icti Loakago/(Mcasmd or Cdoulatod Ilan flow) — 6.OL-
Patis if lunkagu fraution S 0.06
® For A FROSOI, TYPE SEALANTS ONLY - The fallowing diagnostic testing was completed:
(hitt Fan I'rossur talion at rough -in mcasurud leakage (CFM)
C11ECK AFTER FINISHING WALL:
❑ Yom • []No ❑ Pro Q um pan I" or I louso prossurrralion tc.gI
❑. Yes ❑ No ❑ Visual Inspection of Duct Connoutium
THERMOSTATIC EXPANSION VALVE (TXV)
, Y,y ❑ No • '1'h'.r01081011c Expanrion.valvo (or Commission approved
oquivalont) is installed and'Acuc,�ss iti provided for insImtion
Yw is a pass ass fail
0 oUCT DEM- N
1. ❑ Yo% ❑ No RCCA Manual 1) Design calculations have burn completed,
Ihwt Dmign is an thu plans and duct imlallation matcbon
plans.
2. ® Yca ❑ • No TXV is, in.Mallod or Pan flow hex boon voriliud. If Ito "l XV,
variliel fan flow match*: doxip from (314R.
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2 is a I'ai s Pass Fall
' ❑ 1, tho undcrsigntnl, vcAily dwt tho obovo diagllosiio W -t rcRults aind lliq worts I pcifonnW &"ciatcd with the tcst(s) it, in
ounfbrwtuww with Ito mquimmenla lire compliant urodit. I'fhu builder shall provido tho I IEM provider n copy ul'the CF -6R
Agu%W by the builder ctupioya:s or sub -contractors ccrtilying that diaguoaio tasting and installation ntuol Ihu rugoiromonk Ibr
compliance credit.) .
festa Signaturu, Datu 10tallide Subcontractor (Co. Naouo) OR
Performed Gcocral Contractor (Co. Naroc)
COPY TO: Building Departineat
1113118 Providor (il'applicahlc)
Building Owner ut Occuti-iilcy
.)anuary 4, 2001
A
Paso
c
Fail
..
❑
Pass
Fail
THERMOSTATIC EXPANSION VALVE (TXV)
, Y,y ❑ No • '1'h'.r01081011c Expanrion.valvo (or Commission approved
oquivalont) is installed and'Acuc,�ss iti provided for insImtion
Yw is a pass ass fail
0 oUCT DEM- N
1. ❑ Yo% ❑ No RCCA Manual 1) Design calculations have burn completed,
Ihwt Dmign is an thu plans and duct imlallation matcbon
plans.
2. ® Yca ❑ • No TXV is, in.Mallod or Pan flow hex boon voriliud. If Ito "l XV,
variliel fan flow match*: doxip from (314R.
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2 is a I'ai s Pass Fall
' ❑ 1, tho undcrsigntnl, vcAily dwt tho obovo diagllosiio W -t rcRults aind lliq worts I pcifonnW &"ciatcd with the tcst(s) it, in
ounfbrwtuww with Ito mquimmenla lire compliant urodit. I'fhu builder shall provido tho I IEM provider n copy ul'the CF -6R
Agu%W by the builder ctupioya:s or sub -contractors ccrtilying that diaguoaio tasting and installation ntuol Ihu rugoiromonk Ibr
compliance credit.) .
festa Signaturu, Datu 10tallide Subcontractor (Co. Naouo) OR
Performed Gcocral Contractor (Co. Naroc)
COPY TO: Building Departineat
1113118 Providor (il'applicahlc)
Building Owner ut Occuti-iilcy
.)anuary 4, 2001
A