SFD (0310-047)LICENSED CONTRACTOR DECLARATION
��'i h� reby 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
L,,,rofessionals Code, and my License is in full force and effect..
License #, Lic. Class Exp. Date
' Date �"' lkr. 61: Signature of Contractor- 9
,L
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 &;Profession"I Ials
Code). < i , I
O I am exempt under Section • B&P.0 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.
Se( )` I have and will maintain workers' compensation insurance, as required by
6tion 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.
i TATF A. WD � i$it!'3t1I-012
(This section need not be completed if the permit valuation is for $100.00 or less).
() •1 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 pfbvisions.
Date: ,-- tib-n6JApplicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void i D
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellation
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property f • r inspection purposes.
Signature (Owner/Agent) , �, ,.�• . Date
BUILDING PERMIT PERMIT
DATE VALUATION LOT TRACT
23iG
'JOB SITE
ADDRESS
APN
w �r-ti:)ih'.OxiM"eIV' SI"f�"{�
7to'°^: w') -01
OWNER
CONTRACTOR/DESIGNER/EN INEER
(MV (r -- <t f, C,, ::.
k!1r C .,. ' Kf y'vi�Y t7l=,6,WA° C0l,!wd',fi c Y
5144A'`b 11DAMA Ml q
y14o A,Y rfUr,%A,i-I N A41
CAR:[,IMWID
ren. 920
USE OF PERMIT
SPI) ..1.: 7 23,, PLAN 3.A. P91,114iT ,;JO s4 .NOT INCLUDE `E i2!,,OC'•r
INALL18, ,I*0«,:4 , PA OR D1F}T�)'s'VsAY..APpROAC}£ 4%, REDUCTION TO PT.e!!+` i'
CHECK Flak: DUE Tib. •MULTIPLit :'3GITAXC ; CA? c AME I'lJV0 T t PZ
4:E.IVOM CONSTRUMION' 2,20p.00 i>'
PORCII/IP,f TIO 5`77.M SY
�IZ.A,13!�,+tC;A4?P4R'I' �:sfall0 b'I� .
dC U.LC:!TATE.D COFir OF renOJ.YMi.LA UC.�.lL:i.\
' . ��.�.`3� 77.,t.V
ONTRY$CTION fe).X. , 0 r �>�.00.41 e -OW �ItiI14, {lt)
i
M90ROUMAY11 FEE 10"I -D001-421 �000
-000-420-00
PLUle DIH01, It -9 7 01 ;oOO 419.000 $19 0.
STRO O MOTION FP,'' - R X10 401-000-241-060 $23.54
CIRAIJINO FEK
1,1 ?!1`BL.•GPER IMPACT PRX, too. 01)
A11T IN PUBIAC• KAM '• l MIL 2 0-TJO•-445^On1?.
1g0R.%-_TqI~,�% CON 1%1ZU1*-`1f0,11T MD PUA (M1WK
JAN 14 2004
• CITY OF LA QUINTA -
FINANCE DER
}p /
BY
DAT F A fD
INS P C
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Graded"
Return Air
Steel
Combustion Air
Roof Deck S Z
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing p
Compressor
Insulation a
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath /
Drywall - Int. Lath
Final
Final ^�
BLOCKWALL A PROVALS
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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures oe
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Desaft A
I--' C A 0 E C
�8 NERGY
coo
M"V) qlrei-i S
PO. Box 621 Ph/Fax (760) 504-2044
Rancho Mirage, CA 92270 'Cell: (7601250-1852
Email: DESNRG iMAOL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIA.GNOSTIC,TESTING (Page I of 7) CF -4R
—PASADERA PH -6 DATE TESTED 9-29-04
Project Title Date
57-085 MOUNTAIN VIEWASHBROOK COMMUNITIESLA QUINTA, CA 92253 -
_FroL—e_cFAdd_r_e—ss — Builder Name
STEVE VAN LUE 111 760-801-3981 PLAN 2UNITS
Builder Contact Telephone Plan Number
ALAN WEAVER 760-880-5504
- -GROUP
HER Telephone Sample Group Number"
#CCNAW183226 10-1-04 LOT * 23
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: El Tested EJ 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)
E]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 400cfm1ton 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 El No Thermostatic Expansion Valve is installed and Access is
prov,ided for inspection
E