SFD (0310-053)f`r '!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.
S } License ! . ' Lic. Class Exp. Date
3133 10
Date ,Signature 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). +
( ) 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.
(p�j 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.
ate: 14 f7 IA Applicant � L
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, illy nity
& hold harmless the City of La Quinta, its officers, agents and err ees.
2. Any permit issued as a result of this application becomes null ar I id if
work; is not commenced within 180 days from date of issuance uch
permit, or cessation of work for 180 days will subject permit to can la ion. JA
I certify that I have read this application and state that the above infor ati( n is
correct. I agree to comply with all City, and State laws relating to the buildingCIT
construction; and hereby authorize representatives of this City to en r u on F
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) fit-�""" Date .0si
'
BUILDING PERMIT PERMIT#
DATE." VALUATION" LOT. TRACT
r
JOB SITE
APN
ADDRESS
•�/�^fiK �7
.C. "
776;1-Cl,Z0-6A)7
OWNER
CONTRACTOR / DESIGNER / EN (NEER:,•
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.M11 T IN P01.; eft:; PLACES - W,41E r 70.000-IMs-000.
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N 14 2004
OF, LA QUINTA
NANCE DEPT. 1
RECEIPT
ATE /
BY
DAT I ALED
INSPEC g
INSPECTION RECORD
�. OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 Footings
Ducts
Slab Grade ,
Return Air
Steel
Combustion Air
Roof Deck Z p
Exhaust Fans
O.K to Wrap sV
F.A.U.
Framing d
Compressor
Insulation (
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath p
I
I
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set'Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
I
Equipment Location
I
Underground Electric
I
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
Sewer Lateral
Pool Cover
Sewer Connection 7-91
Encapsulation;; ,.
Gas Piping
Gas Test
Appliances
I
Final
COMMENTS:
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
I
I
Final
Utility Notice (Perm)
D6 —? +5
Moon+al n V1 eW
Desert
ENERGY ,, - ` C EC
S�cee --
P0. Box 621Ph/Fax (760) 56472044
Rancho Mirage, CA 92270 ," Cell: (760] 250-1852
Email: DESNRO (MAOL.COM
CERTIFICATE OF FIELD .VERIFICATION AND..DIAGNOSTIC TESTING (Pagel of 7) CF -4R
PASADERA PH -6 DATE TESTED 9-29-04.
Project Title Date
56-745 MOUNTAIN VIEW LA QUINTA, CA 92253 ASHBROOK.COMMUNITIES
roieec— Address Builder Name
STEVE VAN LUE II 760-801-3981, PLAN 3 2 UNITS
Builder Contact Telephone Plan Number
ALAN WEAVER 760-880-5504 GROUP 45
HERS k r Telephone Sample Group Number
_ _, 0,e-0,,,-r.I#CCNAW183226 104-04 LOT 6 1 OF 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.`
® 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.
® 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 93
'If fan flow is calculated as 400cfmlton x number of tons enter calculated
value here 2000
If fan flow is measured enter measured value here ;
Leakage Percentage (100 x Test Leakage/Fan Flow) = 4.65
Check Box for Pass or Fail (Pass=6% or less) ® ❑
Pass Fail
® THERMOSTATIC EXPANSION VALVE (TXV) ,
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is ® ❑
provided for inspection
LOT -
56 — `7 45 Doer - -
Mo�n-ul� ENERGY - C AD EC
S
Pelrvicee
;.
O.. Box 821 Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270 „ Cell: (7601250-1852
Email: DESNRG @!AOL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) - CF -4R
PASADERA PH -6 -DATE TESTED 9-29-04
Project Title , Date
56-745 MOUNTAIN VIEW LA QUINTA, CA 92253- ASHBROOK COMMUNITIES
\
ro c Address Builder Name -,
STEVE VAN LUE II 760-801-3981 PLAN 3 2 UNITS .
Builder Contact Telephone Plan Number
ALAN WEAVER 760-880-5504 GROUP 5
HER ter Telephone - Sample Group Number'
�"'� LJA-1 --1 #CCNAW183226 10-1-04 LOT 6 2 OF 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.'
® Distribution system is fully ducted(i.e., does not use building oavities 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 seat 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 80
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 1600
If fan flow is measured enter measured value here
i
Leakage Percentage (100 x Test Leakage/Fan Flow) 5
Check Box for Pass or Fail (Pass=6% or less) ® ❑
Pass Fail
® THERMOSTATIC EXPANSION VALVE (TXV)
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is ® .
provided for inspection