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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
��/ 714.1/83 B Al10131M
/6ate'(- ��d /3 Signature of Contractor,?,7) • �" / 17 �'
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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.
( ) 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 GOLDEN FAME TNu Policy No.
NWC-344063.42
(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
Y 6e, I shall forthwith comply with those provisions t
ate: - ' A._ Applicant # s�'� 7 �.� ; r /2
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 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.
%tSignature (Owner/Agent) -' _• /f` •f;t !�;�,1-"J) Date -`t/ --
BUILDING PERMIT PERMIT#
(=
VALUATION
DATE. VALUATION LOT
$216,M.90 27 2$714
JOB SITE7�
APN
ADDRESS 7! W -C _ Ilwo
765-49"42
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C"Tny CROVM I,, COMMUM1710
CWrURY CROWLIL CO MMTIES
1535 30. "D" UnMaTf SM'.. #200
1535 80. 'D" STR 'ICI's 9M 0200
SAN MRNA1:cDI, TO CA. 97.408
SARI 1: ERNARDINO CA 92408
(909)3131-60W CBW 2120
USE OF PERMIT
,311TOL1: PAI&.LY DWELL 24G
SItfD:A1i1:AAIi' DOES NOT INCLUDE BLOCK WALLS OR POOL '73% PLAN,
CHECK FRE RMUCTION FOR MULTIPLP ISSUANCE OF SAME PLAN YPE, �
CUS'T'OM CONSTRUCTION 21397,00 SY
PORCHIPATIO ".' 312.00 Sr
0ARA:GE/CARPORT (SF) 11,R3S 60
IMMUTP.D COs° OF C,0NWJUrCn0H
.2,t6WQW"
PJlv12iVRTFEE SLThOdARY
CONSTRUC1'I0I'f FEE 101.000-418.000 S1,049,00
PLAN CNZCX PEE 101-000-439-318 M2.26
MECHAN1CALFRE 101-000.421.000 S`11,O
SLB,C•TRiCAL 101-000-420-000 $136.50
PLUMBING RE 101.000-419.000 $165,30
STRONG 140TION IEE - Rn)D 101-000-241-000 $21.70
C.
GRADING FEF; 101.000.423.000 3'111.00
�;�
DEVELOPER IMPACT PEE $1,907.00
�,•, i
ALT 11d PUBLIC PLAC09 - RES11 701-000.255-000 $42,46
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SUB -TOTAL CON'liil`cl:IC IOR AND PLAM G'1 -MM
$ 3,648.42
LEW PRE -PAW F=
$0,00
TOTAL k`O'Wr MS DUE riOrtM
�:9o��F2
rs
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/—
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck_—�j-�
Exhaust Fans
O.K to Wrap
9 , _ gyp.
F.A.U.
Framing
D
Compressor
InsulationVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final J1:5/ 3j/.a �G�
J
Final
POOLS ASPAS
BLOCKWQyL P PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines/,�
crp
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection-C�
Encapsulation
Gas Piping
Gas Test
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Appliances
Final
COMMENTS:
_—may
Final t �z
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)
Certificate of Insulation
Your Mme bas baen insulated with CertaioTeed Fiberglass instdatien products, Web are ftlgned
far tuday/s safety standards a;rd tmnomow's enemy requirements. -
Fiberglass is irmManie and therefjore permanently nonaombustiblk so it does not have to be treated
-- -- _ _ _--.-.__-.._ _.—_—withfse•�t ahernicels drat 11 e y lose their ei ffixiverot aver aejt has 190 bow tca�t0d-----.----------------
with chena is that tae corrode wiring or mets]. Fibmeam will not absorb tnaistme nor %vii] it
—
cn
This also certifrsea that CertainTeed lRiber.Glass.Insulation has beam professionally imWlcd in this -home
r -to provide the following theanal peerfumanca.
r Job NaKre: Naudaariraa Tracfs 25719 pia th 211 pbme: 1
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------ F�otfiTacs— x-7--Jo>l/kdd�rss3JJdl,-Cetrino•Strce�-La-Qaista,-Ca—
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Ceiling Arm: R-3 S UjA oed Batts Garage Ceiling:
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Laterfor Walb. R -f l Unfsoed Butts
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Sjrbe&qkwcvr.. 011nsmWona Co., Inc.
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Tom Beery, G"mrol lig mmger IJ'keeule Branch
R- means resistance to Iteat flow. The higher the R- value, the greater the insulating power.
Ask your builder for the fact sheet on R- valuesKeep this certificate with you other
valued papers If you ever sett this home, this certificate should be passed an to the buyer.
W a Em M &I i i
SPECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
PE OFO
SPECTIO
[PCRFORMED
REINFORCED CONCRETE CT. STEEL ASSEMBLY O St• (3 IP
POST TENSIONED CONCRETE O ASPHALT -PTHER
O REINFORCED MASONRY O ROE PROOFING
JOB LOCATION ` / n� cax O __ _ � �ko,X„
REPORT SEOUENM NO.
TYPE D
F STaU T r *t-01-1^�4S a
PERMIT NO.
DAG (� /
DAY OF WEEK
MATERIAL DESCRIPTION ft _3 G A _�
RCHITECT
IIS
NRS. CHARGED
WRl.�%
E-a701� S1
ENGINEER
ASSISTANTS
NRS. CHARGED
INSPECTION no" =mt am
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D-Ap-C-JS i u -e-
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT 1 HAVE INSPECTED TO THE BEST OF MJ
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. 1 HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
RE F REGISTERED INS OR��� �` J
OF PORT REGISTER NUMBER NUMBER
INSTALLATION CERTIFICATE CF-611-MECH-03
Pool And Spa Heating Systems (Page I of 2
Site Address: Enforcement Agency: Permit Number:
-101"? OS: C"TU AJb AVF LO CA s. : ' . l 3ntcs
Pool and Spa Heating Systems requirements
§114(a): Systems and Equipment.
W 1. Heater has a thermal'efficiency that complies with the Appliance Efficiency Regulations.
9( 2. Has a readily accessible on-off switch mounted outside of the heater.
Q/3. Weatherproof plate or card containing operating instructions for the pool or spa heater.
[Y 4. No electric resistance heating except for listed package units that has fully insulated enclosures and tight fitting
covers that are insulated to at least R-6. Or if documentation is provided that at least 60 % of the annual heating
energy is from site solar energy or recovered energy.
5. Heating system has no pilot light.
§11 Installation.
V1. System is installed with at least 36" of pipe between the filter and heater, or dedicated suction and return lines,
or built-in or built-up connections for future solar heating.
Q�A cover for outdoor pools or spas that have a heat• pump or gas heater.
V�. Pool system has directional inlets to adequately mix the pool water
6d 4. Time switch which will allow the pump to be set or programmed to run during off-peak periods only
§150(Wump Sizing and flow rate specification
LSI 1. The pump specified is listed in the CEC database of certified pool pumps.
0 2. The pump flow rate shall be calculated based on pool sizing table below.-..
Ct] 3. The pump is capable of operating at 2 or more speeds (not applicable if pump is less than 1 horsepower).
[— 4. Each auxiliary pool load is served by either a separate pump, or the system is served by a multi -speed pump.
Pool sizing (Values are hased an a maximum allnwahle turnnver rate of & hnursl
Max Pool
Volume
(gallons)
Min Pipe D or Greater
inches)
Min Filter Area or more
(sqare feet
Max Pump
Flow m
Return
Suction
Cartridge Sand
DE
13,000
1.5
1.5
100 2.4
20
36
17,000
1.5
2
130 3.1
25
47
21,000
2
2
160 3.9
30
58
28,000
2
2.5
210 5.2
40
78
42,000
2.5
3
320 7.8
60
117
48,000
3
3
360 8.9—
70
133
Note: For pumps greater than l hp. The maximum Pump Flow is the lowest speed default filtration
❑ 5. Calculated volume of pool* 111000 (gallons).
❑ 6. Return Pipe Diameter 'L (inches).
❑ 7. Suction Pipe Diameter 2 (inches).
❑ B. Filter Type �,�t{�i' uat Le (Cartridge, Sand, DE).
❑ 9. Filter Surface Area 00 (sf).
❑ 10. Max Pump Flow 6 (gpm).
i
2008 Residential Compliance Forms
August 2009
INSTALLATION CERTIFICATE CF-6R-MECH-03
Pool And Spa Heating Systems (Page 2 of 2
Site Address: I Enforcement Agency: Permit Number:
System Piping
❑ 1. The suction side pipe is straight for at least 4 pipe diameters before entering the pump (See table below for the
—/ required straight run lengths for various pipe sizes).
Ml* 2. The design uses low pressure drop fittings (sweep90's)
Pipe Diameter Required Pipe Length
inch leading into pump (inch)
1.5
6
2
8
2.5
10
3
12
Filtration Equipment
❑ 1. If a backwash valve is used: The diameter of the backwash multi -port valve 'is 2 inches or as large as the
circulation pipe, whichever is greater
N o -r U Se -0
DECLARATION STATEMENT
• I certify under penalty of perjury, under the laws of the State of California, the information provided on this form is true and correct.
• lam eligible under Division 3 of the Business and Professions Code to•accept responsibility for construction, or an authorized
representative of the person responsible for construction (responsible person).
• I certify that the installed features, materials, components, or manufactured devices identified on this certificate (the installation)
conforms to all applicable codes and regulations, and the installation is consistent with the plans and specifications approved by the
enforcement agency.
• l reviewed a copy of the Certificate of Compliance (CF -1 R) form approved by the enforcement agency that identifies the specific
requirements for the installation. I certify that the requirements detailed on the CF -IR that apply to the installation have been met.
• 1 will ensure that a completed, signed copy of this Installation Certificate shall be posted, or made available with the building
permit(s) issued for the building, and made available to the enforcement agency for all applicable. inspections. I understand
that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to
the building owner at occupancy.
2008 Residential Compliance Forms August 2009