SFD (0307-016)LICENSED CONTRACTOR 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 # Lic. Class Exp. Date
756, B 0.3131/2(
'Date Jh"Xj -3 Signatur6 of Contractor <
OWNER -BUILDER DECLARATION.
I h6reby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, 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).,
1, asowner of the property, am exclusively, contracting with licensed
contractors to construci,ihe' project (Sec. 7044, Business & Professional's
Code).
O I am exempt under Section B&P.C...for this reason 7 --
Date -Signatur e of Owner
WORKER'S COMPENSATION DECLARATION
.1 hereby affirm.under penal I ty,of perjury one of .the following declarati6ns:
I have'pirid,will maintain 6 certificate of consent to self -insure for workers'
compensation, as provide ' d for by Section, 3700 of the Labor Code, for the
performance of the work for whicli this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Skiion 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 OTATE MID Policy No. 157640W002
(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, 1
1 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 -.provisions.
Date.- 2/') Applicant
t
Warning: Failure to secure Worlk4rs'.,Compensation coverage is unlawful and f
shall subject an employer to crimIn nal 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.
11. Each person upon whose Behalf this application is made & each p'e'rson 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 employee ' s.
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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
PERMIT PERMIT#
..-BUILDING
DATE VALUATION LOT .0307-016 TRACT
-7
JOB SITE 52
ADDRESS -700 AVENOWNAVARRO.
APN�
OWNER
CONTRACTOR /DESIGNER/ ENGINEER
cownwORARnidwa
coknEj.bVORUAYFIOIWES
51370 AVM4TJ) _0� BE RAIUD�kS
5 1370 A FS kBERMIDAS
_V
LXQUINTA CA �'.92z'5-3
9
QUINTA CA 2253
(760)58 404 C.t3i 6255,
USE OF PERMIT
9DT012 FAMILY
-1408 SY..",O PERMT DOES NOi;14CLU69:BL0CK'WAL4 Int' 01JSPA OR
DRIVIAVAY APPROACH
TRACT C!ON . STRUCTI& 1,4U0:03 fl3
FORCWPATIO. X00 SF
k1hkAOFJCAXP0RT 81?
87,126 at),
FIARRAOM FEE &TJA9VUQRY
CONSTRUCTION FEE - 101f000-418.000
PILPLN CHFICK VZE 101--000439-318$499.80
r
FEE DEPOSIT
.URCHANIC.AL FNE . 101-000-421-000 $52-50
ELECTRIC,NL FU
PLUMH1'NQ .101-000-419-000
STRONG MOTION RE RESID 101.000-241-000
ORADiNOftlp, .401-000.4 s -t700
DEVELOPERIMPA,CT ft E' q4051,0D
PRECISE PLAN 101-000-441-345
UB-, C0NMU-1JCr1QW AND PLAR CHECK
S 'UB
$3,988.69
IY-23 PRE-PAJD nWS
4250.00
IOTAXi FERIOJT.1'77DUE NOW
JUL 07* -20 3
CITY OFLA
FINANCE DEPT.a V
RECEIPT
DATEB
Y
"r
DATE FINLEQ
JINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_-23 p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
•y/. d
Exhaust Fans
0.K to Wrap
-/ - D
F.A.U.
Framing
Compressor
Insulation
_ Q
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 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
'Water Piping
Q
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral.
Pool Cover
Sewer Connection?j�
-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole 6-7
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 (Penn)
COMMENTS:
DEC -19-2003 11:34 AM P.02
Project Title
z -
Project Addrgss
'A,.�,L/
41,
HERS Rater
Telephone
Date '
h�1t'.r►�l'JD'.1 rail d y..r�� y
Builder Narbe
i
Plan Number
Sample Group Number
rtifying Signature Date Sample House Number
Firm: crr--� �'Ls��%r+y�� j HERS Provider: \'r,�d SSS .45
Street Address: 7� � � �� Gr• ' ti City/State/Zip:. Z4 eUlk -7f -4 92 s
Copies to: Builder, HERS Provider
HERj RgFR COM41ANCE §IATEMENT
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
com ly with the diagnostic tested compliance requirements as checked on this form,
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 comlbination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
I� MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic 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
D 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 Fall.(Pass=6%a or less)
THERMOSTATIC EXPANSION VALVE I
i or Commission a
Measured
values
❑
Pass' fail
uivalent
Yes ❑ No Thermostatic Expanslon.Valve (or Commission approved
equivalent) is installed and Access Is provided for inspection
Yes is a pass
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. ❑ Yes ❑ No ACCA Manual D Design requirements have been met
.(rater has verified that actual installation matches values in
CF -1 R and design on plan.
2. ❑ Yes ❑ No TXV is installed or Fan flow has been verlfied, If no TXV,
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
Yes for both' 1 and 2 is a Pass
Pais Fail
I
1.
Pass
Fail
r
�- Certificate of Occupanc
s oY
V11
4
G 9w5
OF Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 52-700 "ENIDA NAVARRO
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0307-016
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: CONTEMPORARY HOMES Address: 51-370 AVENIDA BERMUDAS
City, ST, ZIP: LA QUINTA, CA 92263
By: STEVE TRAXEL
Date: December 29, 2003
Building Official
POST IN A CONSPICUOUS PLACE