0201-025 (SFD). LICENSED CONTRACTOR DECLARATION
-J 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
$336-70
/Date 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).
( ) 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
Sec'iion 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 VT',11T'I FU14D Policy No.
(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:
licant 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 applicator 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.
Signature (Owner/Agent) _ •- Date—Z - e-)7
BUILDING PERMIT PERMIT#
DATE VALUATION t97SM 16194 J210 LOT 1 C1 TRACT ?0125-1
JOB SITE
ADDRESS 77-901,15., F �' C0
APN 1 +3-M CMI
OWNER
CONTRACTOR ENGINEER
JEJON HMVM
w/oDESIGNER
ixk4SEaORTOGpT(1N
17V564 COMA'=Cf,#O. DRIVT,6137
77-645A CGURMY MUT. D -MY -0 MAKE 150
PA20..1 D1 SMU, CA 92.711
PALM 1'IMMU CA 92260
y
ti'? wy" 72.8224 CDT'.* 11937
1
USE OF PERMIT �.
wwc.1•t J -FAMMY Imp
SP13 , L,OT 10 NIAN .It KUA`t T TDOD'.� NOT 3NIC'UMA Q3r,.43M WAI ..e «%
P0014 SPA OR, DJUVEWAYAPPROAM, 7PYo PLA14 CIwIUX F7,JZ
REDUCTION M-"k:9.R 32",1D.,ATdM OF 3APAE .PLAIN TYP F
CUSTOM CONSTRUCT WN. Z23M)ID VF
PORCHIPa3T(O 1960 se
0ARA,3FJC'ARMRT MIN Sly
f.`O?��T�2i�C'.l'XQ1� T'1�:f. 101�G10t>-�18a00d ��4.40
P14" CHW K WE 10149A.439-319 $192.23
ur"CHNNICALFEB 101 -000-421 -000 $01,00
M EC'F3`MAI, YZE 101-000420-00.0 $Q2176
P'1.,111A THO FEE 101 M000,419.01DO 9162-50
vauxe haarow pez Rmsw 101-000-241-000 $1,8,69
00,C)INa11=EX 101.000,423-000 0.00
DEVELOPER IMPACT FZF,
1*13rd:13, -T%3'I'+ 00 AND PLAN C"£'TMIi,
$3,457.68
[,JAN U 8 20Q2 1 PRS P.Ahm r
$0.00
C fYOFLAQL99 ".OW —.. :O ,NOw
RECEIPT
DATE
BY-�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs - G2 L2!(
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel .
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation U
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall - Int. Lath
i
I
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral J je.7, _ ���
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
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final��
Utility Notice (Perm)
COMMENTS:
sZ
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
uaie
,� 14A-ej-
Builr ame
Plan Number
HERS
Sample House Number
Street Address: /X - 67b v C57
Copies to: Builder, HERS Provider
CF_dR
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested �pproved 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
f ducts)
01-wo
cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination
emiNIMUM
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
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 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)
OTTHERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
Yes ❑ No Thermostatic Expansion 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 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
g ❑
Pass Fail
IL)1�4
❑ ❑
Pass Fail