0201-023 (SFD)A 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
533670 B hic 6/310/02
Signature of Contractor ---* -_
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). 4
( ) 1, 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 S"fATr; 3 UNJD Policy No. 07152
(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 provisions.
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 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 t
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y
the above-mentioned property for inspection purposes. '•
"I ,, , ,
Signature (Owner/Agent)r%�'�%� M - ^Date `'• o 0
BUILDING PERMIT PERMIT"
DATE VALUATION�',� LOT TRACT
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OWNER
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2002
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(CaYOF LAOUNZA
FWANDE
RECEIP�S
DATE
BY��r�
DATE FIN �E'�
INS�CTAR
cam.
?.q,
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
2 . / •— 2
Exhaust Fans
O.K. to Wrap
_ aB_07—
F.A.U.
Framing
Compressor
Insulation
_ r 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
s�'�-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer lateral✓
Sewer Connection
! < 02— �=S
Pool Cover
Encapsulation
Gas Piping
Gas Test
3j "z
Appliances
Final
Final
Utility Notice (Gas) -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final d ✓��
Utility Notice (Perm)
COMMENTS:
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
ress
Builder Contact Telephone
"n-1- lkk--572-3
HERS Rater _ Telephone
t,Ofifying Signature /� Date
Firm:
Street Address:
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
DZZ�&Y►
Built Name
Plan Number
ple Group Number
Sample House Nymber
HERS Provider: ►1 �/
City/State/Zip: 4j. r✓� �f,2S3
CF -4R
r
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.
Distribution system is fully'ducted (i.e., does not use building cavities as plenums or platform returns in lieu
of ducts)
AT -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)
Duct Pressurization Test Results (CFM @ 25 Pa)
Measured
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
L9—THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
ZYes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection Eff-i ❑
Yes is a pass Pass Fail
❑ 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 verified. If no TXV,
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2 is a Pass Pass Fail