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MECH (07-2270)_7T P.O.`'BOX 1504` 78-495 CALLS TAMPICO Lk QUINTA, CALIFORNIA 92253. t BUILDING & SAFETY .:DEPARTMENT. BUILDING PERMIT Application Number: ( 07-00002270' Property Address: 52661 AVENIDA NAVARRO APN: 773-304-019-6 000000 Application description: MECHANICAL Property Zoning: COVE RESIDENTIAL s Application valuation: 4800 Applicant: Architect or Engineer: ---------------------------7---------------------- LICENSED CONTRACTOR'S 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. License Class: C20 Lic e N 834471 Date: �7 Conciacto%' OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the following reason ISec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's -State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).: (_) 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 ISec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden'of proving that he or she did not build or improve for the purpose of sale.). (_) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with -a contractor(s) licensed pursuant to the Contractors' State License Law.). (_ ) I am exempt under Sec. , B-.&P.C. for this reason Date: Owner: CONSTRUCTION LENDING AGENCY hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender's Address: LQPERAIIT VOICE (760) 777-7012 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 8/09/07 Owner: CONAWAY ALAN N 52661 AVENIDA NAVARRO LA QUINTA, CA 92253 r�>> (760)702-3832 ZA 1 Contractor: O r 9 SPEEDY AIR CONDITIONIN AUGUG 9 LOOT 54685 AVENIDA HERRERA QLA QUINTA, CA 92253 ��I11Pt3y; (760) 567-0133 Lic. No.: 834471 ----------------------------------------------- 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. 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 and policy number are: Carrier EXEMPT Policy Number EXEMPT 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 Cade, I hall forthwith �cLo/r� IP µ�wrt�_t(/.se/ptAv�isions. Date: Applicant_ T 1<. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days,from date of issuance of such 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 is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purpos Date: Signature (Applicant or Agent): Application Number . . . . . 07-00002270 Permit MECHANICAL Additional desc . Permit Fee 33.00 Plan Check Fee 8.25 Issue Date Valuation . . . . 0 - Expiration Date 2/05/08 Qty Unit Charge Per Extension BASE FEE 15.00 - 1.00 '' 9.0000 EA MECH FURNACE•<=100K 9.00 1...00 9.0000 EA MECH B/C <=3HP/100K BTU 9:.00 -----------------------------------------------------------------=---------,- Special Notes and Comments REPLACE A/C UNIT ROOF MOUNT PACKAGE UNIT 3.5 TON TO 4 TON Fee summary Charged Paid Credited Due Permit Fee Total 33.00 .00 .00 33.00 Plan Check Total 8.25 .00 .00- 8.25 Grand Total 41.25 .00 .00 41.25 LQPERAIIT .A Bin # City of La Quinta. Building u Safety Division P.O. Box 1504, 78-495 Calle Tampico Quinta, CA* 92253 - (760) 777-7012 -Building -Permit Application and Tracking Sheet Permitfl Project Address: Owner's Name: 7)77 D'Ibi't /i A. P. Number: Address: Legal Description: City, ST, Zip: Contractor: �c Telephone: 9�0-10,2— 3f� 2ST Address:- IkmelzA Project Description: City, ST, Zip: Teldphone: XQ State Lie. #: City Lie. #:Z.,q n-77 7 Arch., Engr., Designer. Address: City, ST, Zip: Telephone: State Lie. #: Name. of Contact Person: Construction Type:, Occupancy: Project type .(circle .one): New Addn Alter Repair Demo . Sq. FL: # Stories: # Units: Telephone # of Contact Person: _T Estimated Value of Project 'goo APPLICANT: DO NOT. WRITE BELOW THIS LINE N 'Submittal Req'd Rec?d TRACMG PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, . ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Energy Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2°" Review, ready for correctionstissue Electrical Subcon'tactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. II.O.A. Approval Plans resubmitted Grading IN HOUSE:: Review, ready for' correctionstissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. -Pub. Wks. Appr Date of permit issue School Fees Fi Total Permit Fees l CERTIFICATE OF COMPLIANCE:. RESIDENTIAL (Page l of 4) CF -1k. Project Tie Date - - O Project Address Building Permit ay Documentation Author Telephone Plan Check / Date Field Check / Date Compliance Method ) Climate Zone (Prescriptive) Enforcement Agency Use Only P 13 Alternative Component Package Method: (check one) C D D (Altemative) Package C and Package D choices require HERS rater field verification and/or diagnostic testing (see CF -1 R page 3) For Package D Alternative see Appendix B Table 151-C Footnotes 7-14. GENERAL INFORMATION Total Conditioned Floor Area (CFA)2vo Average Ceiling Height: 8 ft Maximum Allowed West Facing Fenestration Products Per Table 151-B or 151-C=- (5%X CFA) fie Maximum. Allowed Total Fenestration Products Per Table 151-B or 151-C. - (20% X CFA) g ❑ Building Type: (check one or more)�ingle Family Multifamily Addition Alteration (If adding fenestration fill out WS4R, Fenestration Maximum Allowed Area -Worksheet and see Section 8.3.2 for Additions and 8.3.3 for Alterations) Number of Stories -I_ 1j umber of Dwelling Units: Floor Construction Type:- <2Slab/Raised Floor (circle one or both) Front Orientation' North -/ South / East / West / All Orientations (input front orientation in degrees from True North and circle one). ✓,D. RADIANT BARRIER (required in climate zones 2 4 8-15) OPAQUE SURFACES INCLUDING OPAQUE DOORS Component Type (Wall, Root Floor, Slab Edge, Doors) Frame Type Cavity Continuous (Wood Insulation Insulation or Metal) R -Value , R -Value Assembly U - factor (for wood, metal frame and mass assemblies Joint Appendix 'IV Reference Roof Radiant Barrier Location/Comments Installed (attic, garage, Yes or No ical,.etc, • - - - ---- - -rr ------- - --•-•-^--•�•• • • ••-, , ..., w,aa i ..•�, VY UWAI ,Z) we vaso ror the u-ractor criterion. u-raetors-can not exceed prescriptive value to show•equivalence to R -values: f Residential Compliance Forms March 2005 CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 3 of 4) CF -1 Date SEALED DUCTS and TXVs (or Alternative Measures) A signed CF -4R Form must be provided to the building department for each home for which the following. are, rennirrfl ❑ Sealed Ducts all climate zones Installer testing and certification and HERS rater field verificationrequired.) 0 TXVs, readily accessible (climate zones 2 and 8-15 only)• (Installer testing and certification and HERS Rater field verification required.) ❑ Refrigerant Charge (climate zones 2 and 8-15 only) (Installer testing and certification and HERS Rater field verification required.) OR O Alternative to Sealed Ducts and Refrigerant Charge /TXVs. (See Package D Alternative Package Features for Proiect Climate Zone in the RMAppendix B Table 15170 Footnotes 7-14. OR For additions and alterations, duct systems that are not documented to have been previously ❑ sealed as confirmed through field verification and diagnostic testing in accordance with procedures in the - Residential ACM Manual and duct systems with more than 40 linear feet in unconditioned spaces shall meet the requirements of Section 150(m) and duct insulation requirements of Package D. WATER HEATING SYSTEMS O Check box if system meets criteria of a "Standard" system. Standard system is one gas-fired water heater per dwelling unit. If the water heater is a storage type, 50 gallons is the maximum.capacity and recirculation system is not allowed. ❑ Check box when using Preapproved Alternative Water Heating table, Table 54 in Chapter 5 in the Residential Manual. No water heatingcalculations are required, and the system complies automatically. Check box if system does not meet criteria of "Standard" system, and does not comply with the Preapproved ❑ Alternative Water Heating table. In this case, the Performance Method must be used and must be included in the submittal. Check box to verify thata time control is required for a recirculating system p units ump for a system serving multiple Systems serving sin ledwelling units Rated Enely Tank Input' Tank Factor or External Water Heater Distribution Number Input' or Capacity Thermal Standby' Insulation Type1Fue1 e e in S stem Bwft lops Efficien Loss (%) R -Value serving multi le dwellin units Rated Energy Tank Input' Tank Factor' or External :Water Heater Distribution Number (kw or Capacity Thermal Standby' Insulation e e in stem Bw/hr . (ions Efficiency Loss (%) R -Value 1. For small gas storage water heaters (rated inputs of less than or equal to 75,000 Btu/hr), electric resistance, and heat pump water heaters, list Energy Factor. For large gas storage water heaters (rated input of greater than 75,000 Btuthr), list Rated Input, Recovery Efficiency, Thermal Efficiency and Standby Loss. For instantaneous gas water heaters, list Rated Input and Thermal Efficiencies. Pipe Insulation (kitchen lines ?.3/4 inches) All hot water pipes from the heating source to the kitchen fixtures that are'/a inches or greater in diameter shall be thermally insulatedas specified by Section 150 (j) 2 A or 150 0) 2 B. Residential Compliance Forms March 2005 CERTIFICATE OF COMPLIANCE: RESIDENTIAL (Page 2 of 4) C&IR Project Titlege&q ,L,_ - O.% FENESTRATION PRODUCTS — U -FACTOR AND SHGC ✓ ❑ FENESTRATION MAXIMUM ALLOWED AREA WORKSHEET WSAR —must be included for New Construction, Additions and Alterations. Fenestration #/TypeJPos. (Front, Left, Orien- Rear, Right, talion, Area U -factor Skylight) S li ht N, S, E, W' fl U -factor' Source'. SHGC° Exterior hadinExteri hangsb � Shading/Overhangs"- SHGC ✓ box if WS -3R is Sources included Distri ution ❑ Type and Capacity Efficiency Type and Location Duct or Piping Thermostat Configuration iace heat um boiler etc. AFUE or HSPF 9-1 R -Value a lit or a e 13 1) Slcvliehts are nnw inclnArrl in Wr_f . .. ❑ n�..�aaa ac wLcu w u1G west or ultea In any direction when the pitch is less than' 1:12. See § 151(f)3C and in Section 3.2.3 of the Residential Manual 2) Enter values in this column are either NFRC Rated value or from. Standards default Table 116A. 3) Indicate source either from NFRC or Table 116A, 4) Enter values in this column from NFRC or from Standards Default Table 116B or adjusted SHGC from WS -3R. 5) Indicate source either from NFRC or Table 116B. ;. 6) Shading Devices are.defined in Table 3-3 in the Residential Manual and see WS -3R to calculate Exterior Shading devices. 7) See Section 3.2.4 in the Residential Manual. HVA(' CVCTFMC Heating Equipment Minimum Distri ution Type and Capacity Efficiency Type and Location Duct or Piping Thermostat Configuration iace heat um boiler etc. AFUE or HSPF ducts c' etc. R -Value a lit or a e Cooling Equipment Minimum Type and Capacity Efficiency _ Duct Location Duct Thermostat /C heat CConfiguration. Aum eva ..coolin SEER or EER attic etc. R -Value lit or ck e . Residential Compliance Forms CERTIFICATE OF. COMPLIANCE: RESIDENTIAL (Page 4 of 4) CF -IR Project Title Date SPECIAL FEATURES NOT REQUIRING HERS VERIFICATION (add extra sheets if necessary) Indicate which special features are part of this project. The list below only represents special features relevant to the nrescrintive methnd ✓ Feature Required Forms if applicable) Description ❑ Metal Framed Walls CF -IR Refrigerant Charge ❑ Radiant Barriers CF -IR CF -611 part 6 of 12 ❑ .Exterior Shades WS -4R ❑ Cool Roof N/A; Attach CRRC Label to Forms. ❑ Dedicated Hydronic Heating Performance Calculation. System Required-, Attach Run to Forms* ❑ Combined Hydronic System Performance Calculation { Required.. Attach Run to Forms. ❑ Gas Cooling Performance Calculation ReouireA. ❑ Buried Ducts N/A; Indicate on building plans. ❑ Kitchen Pipe Insulation See Section 5.6.2 Distribution' Systems in Residential Manual. ❑ Multiple Water Heaters Per See Table 5-13 or use Dwelling Unit Performance Calculation and attach Run to Forms. El Water Heating System Per Calculation and ServinR Multiple Dwellings attach Run to Forms. ❑ Non-NAECA Large Water Heater CF -IR See Table 5-13 or use ❑ Indirect Water Heater Performance. Calculation and attach Run to Forms See Table 5-13 or use ❑ Instantaneous Gas Water Heater Performance Calculation and attach Run to Forms See Table 5-13 or use ❑ Solar Water Heating System Performance Calculation and attach Run to Forms ❑ Wood Stove Boiler •Performance Calculation and attach Run to Forms SPECIAL FEATURES REQUIRING HERS RATER VERIFICATION (add extra sheets if necessary) Indicate to the HERS Rater which credits are part of this project and need verificatinn Residential Compliance Forms March 2005 Feature —Required Forms if a licable Description ❑ Duct Sealing CF -6R part 4 of 12 ❑ Refrigerant Charge CF -6R part 5 of 12 ❑ Thermostatic Expansion Valve CF -611 part 6 of 12 Residential Compliance Forms March 2005 M,.ar.—A LWAPsnlu eMaratinn CF -6R -ALT Instanauun- Project Title: Date: ® 2005 CatCERTS Project Address: C6rrnate Pv mors Installing Contractor. Teiephorhe: Plan Check Date V-4- ompany Name: RM Date Check /IMPORTANT- This CF -6R form is only for use when an WAGalbf alteration is n to an existing home Use one form for each system being ides This is systOM of y systems altered in this house. Copies to. Homemnw. HERS Rater, and Ltd the sons for the nerdy estate These must nh; I I the installed equwmt exactly Instated equonerd must matte ttp&qpcabpn and meet or exceed SIR -values from CF-1R- Equipmerd Tvpe Manufacturer Model Number Efficiem Load— CapacitV— Furnace AFUE Heat Exchanger PUA Heat Pump fan col NIA Hydrordc tan coil NIA Other FAU Describe Package gas/AC 2r XYy : Uvi� (. wo I Y� �' SEER Package heatpump HSPF SEER EER* AIC Condenser SEER Heatpump Condenser HSPF SEER Indoor DX cal EER* Hydrorfic col Provide EER d needed for comp6arroe (Fane 24 of CF -IR -ALT)- Bre must provide adequate dc+rmerdation to verify EER In some cases the specific furnace may creed to be verified in order to achieve a specifa; EER In some cases a time delay relay and/or TXV may need to ve verified in order to achieve a specific EER Loads are senshd)le for cooling. Capacities are sense at design oondilirxs for aw&V and a$ltunde, downflow. etc.) for XV: ,W If TXV is required by the CF -1 R fo m (fine 23 on CF -1 R -ALT form), it has been irsta/ed and access has been provided for vel vedficafian by HERS raterSampka is 2 'for TXV vim. Entirely New Duct System (Line 5 of CF -1 R ALT) O For Entirety new drat syste s, the nmp*ed leafage is 6% rather than 15% *w aJlere 'systems, The eve to duct sewm by increasing the emciewy of the is not as cyrion, for en&eil mw dud 1. the undersigned, verify that the egri liment fisied.above is: 1) Vie, ahemll eatipmeet insialed in the home; 2) equal to or nae efficient than required by the Cerfilirate of Cie (CF -1 R -ALT Form); and 3) equipment not meets or ehooeeds the approlaia6e Uiremerrfs for mamdachaed devices (Appliance Efficiency StandardsX where6 11 I, the undersigned, verify Ural diagrhasfic test reshits laded on Bis forty we Iarme 'in carI wilb the requirements for mptiance and that the new* inste,ed or ref est rrhedhaniea< system components eonsinnrh wdh Uhe R4ardatery r specified in Section 150(m) of the 2005 Bufting Energy Efficiency i nshow otes: verXM vs -1U -M rage i or z This form can only be used on projects being verified by CaICERTS oeu l rater& warn- calcerts.com Certificate of Field Verification Prescriptive Method - r%; fit- Toctinn uver'-.o%wslw elbratinn CFAR-ALT 17 O 11faml5isdieded61tnut 143114b,Sod"aramvaa -��-- -- step6-keakewtoOdsdefolftalm i&dramBdcnCF Nt-ALTfo®} 18 = nAwft2OO5ACIkqPpendaRGSwG—RC433 19 O am I i- rasa tim 9oe8 liners fire to otside 20 0 hmaedwSDA the %!d& F3te5t AttalkrarCF4RALT Seeaakes.beeJaas Project Till: Date: ®2005 CaICERTS rn G� +�� Cc •/CPo IMPORTANT: This -4R -ALT form s only for use when an HV�Ny alteration s rte to an �st�►9 home t of attered m Ohs house. Use one form for system being altered• Ths's syStern _-sys� les to: tlomeoMr+m� installer, and nt Rater to verify only results of test that passed an CF -6R -ALT far See Enos 26 to, 29 of CF -6R -ALT form. Results must be uploaded to CaKX913 Rewstry for woe of final catIcate, per Title 20 Step t _ pf.test Leakage ddo Deroreawdims drme27isrlredadODMeCF61t�1LTtmn. 1 IORM Frain kine t d CF -GR -ALT keine. 2 Liner xo.4= Step 2 - Oeterrnirre TGWSVsh=RmFkwr Use dame methods a goes 2rx27 or ZS aecheded m CFS i1LTtam I ICFM 3 Condel>st+rlor Mm ft=x4DDCFU4m= 1 &00 4 JCFU F umaoe Ot4w& and mode!nramberofeautront 1 9aDnbartorbPorinsralerdoh vei �Cierroes_ 5 (refer to ACU Mwuai Appenft FtF- seciiom 4.1)= Luasummati Mwhocd 0 OaomResmmmatcl Otlaargrsd e QCr r� 7 ofd fantiar�tobeased Step 3_pdetroitreTatga�(Od9ifires2Sar26ated>rx3rdmCFSRa1LTtorm)=6�4�9d 8b steal famsorr 7tra® zOtS= -�' =tax taaatsde g oral System Tensa. Ob2e7rram abowoxat0= 17 O 11faml5isdieded61tnut 143114b,Sod"aramvaa -��-- -- step6-keakewtoOdsdefolftalm i&dramBdcnCF Nt-ALTfo®} 18 = nAwft2OO5ACIkqPpendaRGSwG—RC433 19 O am I i- rasa tim 9oe8 liners fire to otside 20 0 hmaedwSDA the %!d& F3te5t AttalkrarCF4RALT Seeaakes.beeJaas Step 7-(6fine2sisdfedoatn0eCF6R 4LTtans 21 O Test ardVfsc�rgpedimdAWOMUR uclSea>u+gm M eel 22 0 reqrgradrsbdperACUAppsnftMSrdmsRC4� 23 0 res NOF Oe d a O - horaedm5ad7etpesstheoeoessf►tads Rdedn�giaed an wWCFdR-ALT_ seeooles,bdos► Step a-$roloeTestadVisnaVeacom Ekm27ac29methedmdant LT 24 25 26 0 smaketmApe6ACYAppadocMSadcmRC4� 0 visfla/, , r, adVOSj►MPakd A-,-MoerAOiMP MRC 4.3-71 O �UsavegliSubods_—_oDsmmwmdogumkmdperACUAppendzMqe - RC43J- Ishm 9-TXV a TXV s rer�ied by fte- CF -1R norm (foe 23 an CF -IR -ALT four* d las been asked and access 7b been W usual v+e�5on HERS rater 0 'RaftkWrw t Charge and PAIW rte' (see ACU epi; , . tin) t dome in leu of T7C\f, atiatd! oorflplel>ed 3 of 8 ad 4 of 8 from tine CECs CF 4RfwM StSV 10- 28 Oupgrade equipawd , Ma - - are reI >(8[re 24 of CF lR-ALT)Hers rater b ve rgy tit and mode!nramberofeautront 1 9aDnbartorbPorinsralerdoh vei �Cierroes_ Notes: refer to fine numbers above e QCr r� Certificate of Field Verification prescriptive Method - and Diagnostic Testing HVAC -only Afteration CF�f2'ALT Project uie: vane: ® 2005 CaK:tK I s Erdoraemem Use O Project Address: Climate Z�'Penrst # Lk-..) - �y •Ut.Wdd o� � �le.✓�� c. livav�v Installing Contractor ems-eck Date 76a e� C 6 , p Cal RTS Rater Name: ib:s tame '769 CaICERTS Rater ID R tees Company Name: D A . C DD Z16 9,0 IMPORTANT: This (;F -4R -ALT form is only for use when an HVAC -only alteration is made 1501 an w=WV home Use one form for each system being armed. This sys150m # of ;e- systems allured in this hotw- Do not relmse CF-4Rs for a sample group Urtl al venation and testing in the group's compleled and passed - Copies to: Homeownw. habler. and Hers Rater Con0ance Statement As the HERS rater provid V diagnostic t esb and field tri. t eer* that the house dentified an this fort complies with the dragnostic trrsfng eoaplantoe teVxmMdS as docked V on this form 1 also certify than 1 have followed ae protocols and prooedtms as req u 'by the CaICERTS Rater Agreement Signed: PMV irst Re-Wd (eftadr P CF -4R -ALT) nus house is NOT pad of a house ate tests foHHiS rater Staten t E3house dd NOT passttie tests Rded Slee tales beton and red page_ house's pat of a sample 9ouP 08w hours it i ww" irdnde W= 6y ❑ Horne a+eeters fast rian�red 1) 2) 3) 4) 5) 6) ' house pees ad rreDPssarp tests (haler b sign tnBiS rater aompiaioe statemerd above). hortres hr � be Wired Ct=�t Cer�Sr�es lean Car(;ERTS ❑ horse dd NOrT paw the necessary fest Relr3 noel See roles b A and red page: ❑ This-sffiefirsthocaet ofaiirth'sgoup. (SiAemeafft weird. Iffsemrdte* ❑ This is the woad mise lo fol in this group. /a' w gaup rmat be laded Notes: Version 03-10-06 This form can only be used on projects being verified by CaICERTS certified raters. www.calcerts.com