SFD (0310-043)fn
U)
w
p �CY
W
r-- Ck:
Z
to O O d
J
r`
F-
cn =
z
LICENSED CONTRACTOR DECLARATION
I,l ereby'affirm under penalty of perjury that I am licensed under provisions of
,Apter 9 (commencing with Section 7000) of Division 3 of the Business and
;Professionals Code, and my License is in full force and effect.
X. License # Lic. Class Exp. Date
16 03 35Y il 105.
Date t �.-ti�a Signature of Contractor--.-
d
` 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.
(;t)' 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:.
Cartier Policy No.
Si.A't`E YiND I a3 7 l)1.i
(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 provlisions.-�-j W
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 m
whose request and for whose benefit work is performed er or pu73-
t to
any permit issued as a result of this applicaton agrees s a , Mnnlhold harmless the City of La Quinta, its officers, ag s nd mmes2. Any permit issued as a result of this application bec a nulJgQp.a} 2
work is not commenced within 180 days from date , f i uanceuch
permit, or cessation of work for 180 days will subject -p rmi teQU
I certify that I have read this application and state that•the above infVMllWMDEI
correct. I agree to comply with all City, and State laws re ating to t e building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for iin pection purposes.
Signature (Owner/Agent)-eft - a -M-�M Date
BUILDING PERMIT PERMIT /t
DATE VALUATION LOT TRACT
l r �,v.ti qq, ry p 7,9.+4:x'2
JOB SITE
APN
ADDRESS
11
OWNER
CONTRACTOR / DESIGNER / EN INEER
t°-RY Wir.'+ iii+' , LP-
p: .L i C3� fig. r9 ' fi ` T �S; (,Q►? �11*A"
C 00
:�4i��✓�SDF✓�."t'°��a7C7. ' a.�LJ3wTf; �.� P� _
USE OF PERMIT
( � y{ � g qty S
i3'=ZV�i/:1:�t�1... �17AMF,'�...9. 15�1I%;,'.�4�.:2..�LK•d�.3
SYD . L07116, i%'1,.F,,0 WM PERMIT j~)O1A S'NO°i ITd(:i: UDE B -OC.1:
WAf.LZ, O'A,,,'5'eA aR I�F`NW?eY APP.hOiLCK 1J�'✓o 1iEI7'Zfi T1014 `m
F'I..P41.4 t: II %:Ia MIR OUZ TO XIIJI `!' PLE ISfi AI E ")F aAI> E 3)I Js,1 't ``I]9F, r �.
CUSTqq,, q R {. f. 19
„l
525.00 SIF
MIATED COSr 01P IC ►Z MON
�^��, q•' p} �Sy,. �tY,H,?
F JIL•�.�d�.V dL:i': S'clJt�.X:'W:Y./63C,7.
TRU(4"KM &EI*.' .. 101400-418-000al,or . a
PLA14 c;RWX' We .60,21 �4
,�`fi�t"k:ti`�T�df:.�Lr~`;�,'�� 2(I'j,:Ut?U�1•'�:lrt�C•� 49ll.inf
?Y.;N?VYWC.J3,I.n MKIP,'
<S.I.kl:iM MOTI4Y;'; MA,, • l3l wil? I W-000441 -600
c'.91t&DD10 FRI - l o i-000;4.1 r-000
��V'L'I.,i')PI�1.IhK;�.�.I�° l�xi'.f; ' ��4U�•�
AUiT1NPUPLIC P3 A4.k��
�'�3i � t€Tapt ly ARIL 1+ .�,hi Cn,
, `. x'7.39
NTA
RECEIPT
DATE
BY
DATE FI D�
JJNSPECT,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
p
Combustion Air
Roof Deck
,s Z
Exhaust Fans
O.K. to Wrap
C/
F.A.U.
FramingZ
p
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/Z p
Drywall - Int. Lath
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 v
Sewer Connection
d
Encapsulation
Gas Piping
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
4;6
56 s DiHr sw-t
E ERGY - 4 E t
1
130. Box 821 Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270 Cell: (760] 250-1852 '
Email: DESNRG 9lAQL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOS"TIC TESTING (Page I of 7) CF -41R
PASADERA PH -6 DATE TESTED 9-29-04
Project Title Date
X5666-945 MOUNTAIN VIEW LA QUINTA, CA 92253 ASHBROOK COMMUNITIES
r LEVE VAN LUE II 760-801-3981 Builder Name
• PLAN 2 2 UNITS'
Builder Contact Telephone Plan Number
ALAN WEAVER 760-880-5504 GROUP 5
HER er-�`�'�"") Telephone Sample Group Number
;CNAW183226 10-1-04" LOT 16 "
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
z
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 comb_ ination 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)
'
Duct PresMeasuredsurization 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)
❑ Yes, ❑ No Thermostatic Expansion Valve is installed.and Access is '
provided for inspection [l ❑