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LICENSED CONTRACTOR DECLARATION
J hereby affirm under penalty of•perjury that l am licensed under provisions of
:-`",Chhapler'zJ (commencing with Section 7000) of Division 3 of the Business and
F�rofessionals Code, and my License is in full force and effect.
License %i Lic. Class Exp. Date
760335 l3 C3 i 1/2(
Date / / fSignature of Contractor ✓'� �� - --.
:✓ - ---
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- hareby affirm under penalty, of perjury one of the following declarations:
O I have•and.will maintaiaa 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
Seation 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 siA1±� rIFj Policy No. 1tSt►�isp.1-1112
(This section need not be completed if the permit valuation is for $100.00 or less).
(,f) I certify that in the performance of the work for which this permit is issued,
'Ishall 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
CodeJ shall forthwith comply with those provisions..
Date ,1 f f 1hy,1 �� Applicant A X-,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in to,
3706
of the`Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose,behalf this application is made &-each person at
whose request and for whose benefit work is performed under or pursuant
any permit issued as a result of this applicaton agrees to, & shall, indemn '
,<#.4 hold harmless the City of La Quinta, its officers, agents and employe
2. Any,,;permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of su
permit, or cessation of work for 180 days will subject permit to cancellatin.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the buildi
construction, and hereby authorize representatives of this City to, enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) .p"%��.-�_' Date
BUILDING PERMIT. ` PERMIT#
DATE jj S r VALUATION ' LOT TRACT '291
JOB SITE
ADDRESS -7M1V[0UM, 'A11
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
(MV 1% 0 L 19M
fi.MMR 0K. L�.EVF 0.PN4 �'i M, WAN Y
S 140 MMODA. MCINNS
3'140 AWINiIat• ENCj-I NS
CARL BAD -,CA 92008
CARLSBAD , CA. 92008
7
USE OF PERMIT
B114GLY J~RAWLY 1MMWO
5170 = LOT 4, PLAN Wk: PERMIT DOES 14'O'1';iNCLI UD7, 6LOCr W11;Ld13, .
POOL. SPA OR BIRMEWAYA['1?'ROACH ?-$% rkEDUCTION TO P31AX CHECK
FLIS Alla ` O MULTIPIX ISSUANCE OF SAXFo PL;v4W TYPE
CUSTOM CC06TR1JdT10N �501,00 OF
1 oppa rPATIO ' ` • 55&00 S1''
0MAGEMARPORT 60100 OF
XkS`1Tt 4A1 C09Jr OF' GC)NSTi:3UCITCIN
23.4,10730
PROWT MR, SUMMARY
COX01 Ttl[7G""TION FEE 101-.400-4-18.000 $1,04, 2.00
PLAN CH Ct CK ".11
MECHANICAL FEE � 10.1-000.421«000 5111,100
ELECTRICAL ",3 101.-000-420-000 $1513:14
Pd.UMBiNO ME ,� 101 OGQ-419.000 $197.75
STROJ`14 MOTION FEE RL' UD: 101 x(00 -^r41-000 $21.41
OR.P.11I1 G PES• '1(11-000.42'3.000 �tS.dfl
l:lET'El.,tlPER IMPACT FEE...
ART IN PUBLIC PL CW - kpir 370.000--.45.000 333.r~
- .31M -TOTAL MO V YT.Y R V M`+iSt AND .1C:.dM1 CSWXK
$4,114,45 _ • .
TOTAL 1-%ERMIT DUE NOW
LNOV
$4,174A5
14 248.
CITY OF LA QuimTka
FINANCE DEPT
RECEIPT
DATE
BY ,
DATE FI ALED
INSPECT -QR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
ti BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings „
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck%/ p
Exhaust Fans
OX 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 a
Qjywall - int Lath
--7
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 APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Seaver Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
4 '44Z
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.J.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
' Mounf4Desert
n q; ENERGY.- A 0 E C ,
Services 4
y
P0. Box 821 Ph/Fax (760) 564-2044
' Rancho Mirage, CA 92270 Cell: (7601250-1852
Email: DESNRG rdlAOL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PASADERA PH 4 DATE TESTED 6-14-04 v
Project Title Date
P.G.A. WEST LA QUINTA .'ASHBROOK COMMUNITIES
Project Address Builder Name
STEVE VAN,LUE II 760-801=3981 PLAN 1 2 UNITS .
Builder Contact , Telephone PlanNumber
RICHARD KROWN 760-250-1852 CROUP 4
HERS Rat Telephone Sample Group Number
` #CCNRK613292 JUL 212094 LOT
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. 92210
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. w "
❑ Distribution system 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. '
❑ MINtMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTIOWCOMPLIANCE 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 Fail.
❑ THERMOSTATIC EXPANSION VALVE (TXV)
t ❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is ;
provided for inspection ❑ _
v� .