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c•« LICENSED CONTRACTOR DECLARATION
I h6eby 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.
C: Licensel# pt t Lic. Class i Exp. Date" fMC
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Date } 144) 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'owrier of.the property, or my employees with wages as their sole
compensatiori;: mill do the work, and the structure is not intended or offered for
sale (Sec. 70441.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.
(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 sh II forthwith comply with
tho!�e'provi
,,, s.it'o"ns.
Applicant Date:
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
any permit issued as a result of this applicaton agrees to, & shall, indemn
& 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 cancellatio
I certify that I have read this application and state that the above information s
correct. I agree to comply with all City, and State laws relating to the buildi g
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property fob inspection purposes.
Signature (Owner/Agent) ! ".t'""`` Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT . ; -TRACT
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JOB SITE
ADDRESS
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OWNER
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S/DESIGNER
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C4ARUMAD CA -2408
CAMEARAID CA 92.0,0181
USE OF PERMIT
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COMTitilCTIONFEE V0 MOP
PLAN CHECK Wl,Z 8
MECWNICAL "OR 101.0004 I ,,00a
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CHECK
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JAN 14 2004. 'a � :cx a:�� `:��.eN umt; nb+�
`• CITY OF LA QUINTA.
FINANCE DEPT
RECEIPT
DATE
BY
DATE FI LED
INSPECTOR '
f 11
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/
Ducts
Slab Grade
v(
Return Air
Steel
Combustion Air
Roof Deck
p6 Xv.
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Rln tv
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
Z
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
��!-�7el
Encapsulation
Gas Piping
e 7
Gas Test
Z 6
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
_
56 -g85
M0lJV\4a_M View
Demon - -
ENOJERGY ��- CAD EC
CBS
Po'. Box 621 Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270 Cell: (7601250-1852
Email: DESNRG 9DA0L.00M
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7)
PASADERA PH -6 DATE TESTED 9-29-04
Project Title Date
X56-885_�MOUNTAIN-VIEW-LA-QUINTA, CA 9 22 53 ASHBROOK COMMUNITIES
r c Address Builder Name
STEVE VAN LUE II 760-801-3981 PLAN 3 2 UNITS
Builder Contact
ALAN WEAVER
HER&Fater
83226
Certifying Signature
Firm: DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
Telephone Plan Number
760-880-5504 GROUP 5
Telephone` Sample Group Number
10-1-04 LOT 13
Date Sample Lot Number
HERS Provider: CHEERS
CF -4R
7�
City/State/Zip: RANCHO MIRAGE, CA. 92270
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested to 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 Diaanostic Leakage Testing Results (Maximum 6% Duct Leakage)
Duct Pressurization Test Results (CFM @ 25 Pa)
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)
Measured
values
❑ ❑
Pass Fail
°s
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑ ❑
provided for inspection
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