SFD (0310-039)LICENSED CONTRACTOR DECLARATION
U), ` Q hereby affirm under penalty of perjury that I am licensed under provisions of
I_ � Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W' �Profeii`ionals Code, and my License is in full force and effect.
p �rj License # Lic. Class Exp. Date
r ` Q LO
LU
o Z r` Date Signature of Contractor
CSO 9' ",r
1.— Cp OWNER -BUILDER DECLARATION .
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) License Law for the following reason:
Z ( ) 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).
e') () I am exempt under Section B&P.C. for this reason
LO
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.
( k) 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.
i1 ITE F"VV"r.`3 i.tf�s30I.�1!
(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. -riot 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
§ubiecf to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those�rovisions.
Date: Applicant—
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 un
any permit issued as a result of this applicaton agrees to, all, inde I
& hold harmless the City of La Quinta, its officers, agent emp oyees.
2. Any permit issued as a result of this application becom n II and void if
work is not commenced within 180 days from date of u nceJAMcJ
permit, or cessation of work for 180 days will subject per it t cancellation.
I certify that I have read this application and state that thpLab ve Ino psLj
correct. I agree to comply with all City, and State laws 'relat g to the bVVMFl I
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property f r inspection purposes.
�SSignature (Owner/Agent)0•�-- Date
BUILDING. PERMIT PERMIT#
DATE, VALUATION LOT �3�.: TRACT
• 1�:., .,,x,/ S221. 1 51.40 17 29',147,.•,
JOB SITE
ADDRESS y. -f --
APN
OWNER —
CONTRACTOR / DESIGNER / EN (NEER
�.r�!�,H
5140?eEINTD.ENuAS
'51'40AVERID.A.MNCMAS
0} 0!3.6M8 3376
USE OF PERMIT
.sir :i,�1'dryry�Xg(�.���1',.;i�4�T{�,�ppe
1 67 �n�pp {7+ ,r t s
wD3'D n I.t;IT A3, R'I.ta>N OAR.. i7�,RMIT .C'OIR.,'.'s NC. T s�i�.sii..nta`1. Z ULOCK .
PL
PI. AN CHWIC FE'd. Di,J':E ` O MUL7HPLE ISSUANCE, 0Y ."Z PLAN 'F'aTT;
NA
POUF?;CI a3?�t?1.U��U
/�(u�'P.fryll'Sdyi{�t�it �Sy1i
1.:X,..�.fi.W .,�'MA�TI.S'Vliia Jc)••„•.•V Dl
X91 '.. TED COST OF CONS 1RTM•O.Pi
221:3.57,40
$"' I. AN GHVX %' F.t Z. .1 0'.t "iJca4 `9- 316' ' .p/ S! • �
MM-HANICA,ME 1,01-000-1,21-000 TM100
.
E IYZTPJC M F41, F. ..
F'lsi�i'�..Fsri•3W F�:�: I OY'��)�it3';W# i� G�f 54�,• :l�
STRDNO Ma,.;TION.IrE ,. MESIO 101 :000-24,1-00•x+
Celid�t»�➢AICi ITE. 10
AVIT W PUSI f: UCx',,89
'
t
LF 5 RDIPAID M.0
1K.00
2004 . ycyxaAL P � K w DUF, row
t ,
J.,
UINTA
EPT.
RECEIPT
DATE
BY
DATE FIN LED
JINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
s{j
Return Air
Steel
Combustion Air
Roof Deck
a
Exhaust Fans
O.K. to Wrap
L
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 p
Drywall - Int. Lath
8Q
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Ze
Encapsulation
Gas Piping
Gas Test
Z
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduct
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels CJ
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ervgces�
..Po. Box 621 Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270
Cell: (7601250-1852
Email: DESNRG 9DAOL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Pagel of 7)_ . CF -4R
PASADERA PH -6
DATE TESTED 9-28-04
Project Title
Datel
56-865 ' MOUNTAIN VIEW LA QUINTA, CA 92253 _
ASHBROOK COMMUNITIES
Wroject Address
STEVE VAN LUE II 760-801-3981
Builder Name
PLAN 2 : 2 UNITS
Builder Contact Telephone
Plan Number
ALAN WEAVER 760-880-5504
GROUP 5
y
HERS,Rapter TelephoneSample
Group Number
#CCNAW183226 10-1-04
LOT `- 12
Certifying Signature Date
Sample Lot.Number
DESERT ENERGY SERVICES HERS Provider:. CHEERS .
Flrm.
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
a
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Press urization, 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 (l00 x Test Leakage/Fan Flow)
Check Box for Pass or Fail (Pass=6% or less) El [I
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
F! Yes . ❑ No Thermostatic Expansion Valve is installed;and Access is El ❑
provided for inspection
AY -
LOT
566 �� -
CADEC;�� En ERGY.e_
130. Box 621 Ph/Fax (760) 564-2044
- Rancho Mirage, CA 92270 Cell: (760125.0-1852
Email: DESNRG CWAOL.COM 4 '
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PASADERA PH -6 DATE TESTED` 9-29-04
Project Title.. Date
56-865 MOUNTAIN VIEW LA QUINTA, CA 92253
ASHBROOK COMMUNITIES ,
r0 eec ress Builder Name
STEVE VAN LUE II 760-801-3981_ PLAN 2 2 UNITS
Builder Contact Telephone Plan Number Y .
ALAN WEAVER 760-880-5504 GROUP 5
HERMater Telephone Sample Group Number
k)'Q-j� #CCNAW183226 . 104-04 LOT '12
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.
in
❑ Distribution system is fully ducted(i.e., does not use building cavities as plenums or platform returns at 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
Y value here
If fan flow is measured Enter measured value here 1
Leakage Percentage (100 x Test Leakage/Fan Flow) = 0 ❑ E
Check Box for Pass or Fail (Pass=6% or less) Pass Tail
❑ THERMOSTATIC EXPANSION VALVE (TXV). P
❑ Yes [] No Thermostatic Expansion Valve is installed and Access is ❑ '
provided for inspection
e� ��Z � �"l �' _ _
;°
�F
c
s
L
�.
�:�
i