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LICENSED CONTRACTOR DECLARATION
.I hereby affirm under penalty of perjury that I am licensed under provisions of
6%.Zhapter 9 (commencing with Section 7000) of Division 3 of the Business and
V'Professionals Code, and my License is in full force and -effect.
License #n Lic. Class i Exp. Date '*
6Date' `� 1tf rSignature of Contractor
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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 fo.r
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 reasonr
Date 4'' i Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm'tunder 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
Segfjbn 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 , TNTE NQWO . Policy No: 160001=01 .
(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 shlal fort with comply with th se rovisions.
A lata e; aTri f! %2Applicant �*^--. - —
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1100,000,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 t
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 insspp-e-c•tiionn purposes. rr
,,,,Signature (Owner/Agent) '"----+�`�----- Date f Ll f� `1
BUILDING PERMIT PERMT#
7
03011_377
DATE VALUATION LOT TRACT
I 1 'J l,8, 'iQr1 . .2 '29147.2
JOB SITE
ADDRESS 5S^":5 MOF%I,7�ii #,TAN VIP
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
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C"Alwl. SA,D CA 92008
CARLSBAD CA 92008
USE OF PERMIT
aCl 0,!Y_ 1fiAMrJ_Y DC1JELUN
:SPT) • L T'% PL.M 21311,. F'IPRMITMOPS-NOT INCLUIDE BLOCK WALLS,
PC:sOL, SP.ArOR D1tNEWAY AVPROTA'Citi'59C, ,PEDUC 1'ION TO PLAN Cl-IRCk
PEXEILIZ TO MULTWLE ISSUANCE OFSAME PLAN "TYPE
CUOTOM CONSTRUCTION 4019.04 SR' .
PORCHMATIO ' 525 03 SF
GARACIEIC"ORT 534-00 UP
F.7DEIE7.ATED COST OF C2MMRUC-110-N
�21,1a7.6€D
1'E TEE SJMMAR`
ClJNST;WiCTION FEE 101406-418-000 Y1,mso
PLATS CHECK FEE $47.42
MECHANICAL FEE 101-000421-000- &1i t.,00
ELECA'WCA.LFBI, 1.01=000-920-000 $135,71 ;
I'Lt�fz9l�lAiOI1'aE 101aC100t43x• +00 $181.71
STRaNO Nf3'I'ION FEF - RZ`31D • • 101-000-2A1-000
GR.ADINO FEE 101.-00,0.423.000
DW-W-IDPER IMPACT FEE' $a,�➢A .04
ART IN PUDLIC PLAC{M-,1T.011 i!0-000445-000
i
0U.B-Z'CYPAL CgQ3.1 tRXJC'$OAT AIM PT.f�s crTu'T
$4,20.39
` LEM PRE -PAW RMS
$0,00
TOTAL ,1?ET�iV ..1' IrFI ;6 ?011 HOW
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;4,207.39
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6 O 14.20063'
CITY OF LA G'uLjA oA
FINANCE f:tEPT. Y
RECEIPT
DATE. -
I l• l�if a
BY
DAT FI 3LED
/
INSP CT
-
INSPECTION RECORD
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
Jr
Exhaust Fans
O.K to Wrap
y
F.A.U.
Framing
Compressor
Insulation
o p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
b
D I - n . Lath
/ p �E1
ul
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 APPROVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Paris
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
1
Final
Utility Notice (Perm)
COMMENTS:
L®7-
56
Dewrt -
-665 ENERGY ��� - CAOEC
M0AwI �J 0EvJ s
P0. Box 621 Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270 Cell: (7601250-1852
Email: DESNRG MAOL-COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC- TESTING (Page I of 7) CF -4R
PASADERA PH -5, DATE TESTED 6-14-04
Project Title Date
P.G.A. WEST LA QUINTA ASHBROOK COMMUNITIES
Project Address Builder Name
STEVE VAN LUE II 760-801-3981 PLAN 2 2 UNITS
Builder Contact Telephone ' Plan Number
RICHARD KROWN 760-250-1852 GROUP 4
HERS .otL Telephone Sample Group Number
#CCNRKS13292 ` JUL 2 2004 LOT : 2
Certifying Signature Date Sample Lot Number
Firm: DESERT ENERGY SERVICES HERS Provider: CHEERS
Street Address: P.O: BOX 621 City/State/Zip: RANCHO MIRAGE, CA. 92270
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house,was: ❑ Tested ® 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
with the diagnostic tested compliance requirements as checked on this form.
❑ The installer has provided a copy of CF -6R (Installation Certificate.
❑ Distributionsystem 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.
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct, Diagnostic'Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM
If fan flow 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) ❑
Pass
EJ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection