0201-026 (SFD)LICENSED CONTRACTOR DECLARATION
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
33611
0 .har. 6/30/02
ate "- 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. 7.044, 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 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 ST T8 FUND Policy No. 07132
(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' compen sation.provisions of Section 3700 of the Labor
Code, I shall forthwith comply with'those p o isions.
,Date: Z" ,,Cn f -A,. Applicant 0-/�l -
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.
r r S
Signature (Owner/Agent,- Dater
. t.A
BUILDING PERMIT PERMIT#
V
0201-026.
DATE i t VALUATION �ddpey`r 60 LOT TRACT
t1,f� 4:✓r- dd ,ri
JOB SITE 1
ADDRESS s•:� .S,� SP � 0U
APN 7`7':4-C► � (B,yn.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
M�014A1-10 9
S'd:i1'1ROS C(YRP012A110).,'
77-564 C'0MMY MU1311 WW'0137
150
'O.A.Ilm DMIERT SPA CJ2211
PALM TNENIEU ' t.:A 92260
USE OF PERMIT
MGM YAMLISDWALWI3
SFID • 1;= I I PLAN YP, MRMI'! DOES NOT YNCLUIar' Ba'flClK WALLA
P001, SIR& OR i7{31 E WAY APPROA.CK -7rY* PLAN CNEM PER,
RZOUC T1014 FOR ISSUANCE OF''StA;ME PLAN 'i i'"P'"&
CUSTOM L:K3"rtM'a' UCt ION 2,480.00 all
PORCHWAM, 123.00 SFS
�if+�t2�:a �'�1xP!�1�.1 tiiiz3,Q0 �)7
COS' OF CO,NG111lu ' low
2079M.70
akON T£IRVO ION M 101•(300-418,,000 $1,017.0
FLAN Ck•Iit ZiK FRE 101-000-439-319 Of�''r n
NMl CF111MCI ,1.,1M19 101=000-421.000 4;109.0
P1.��OIF,�e�f�:ir'b'�L? 1 U 1 EO(341�4,14.0(1P� �1 s+59D-
STtE,ON13 A40'91014 :i is • 91,00 10'1-000-M-1-1)00 S^79
OPIAD1100 FIE 101-000-423-000 $20.00
DEV1310PER IMPACT FEE, S1; V.00
.AWr 1N PUBLIC KAM ^ R ' 31 , 270 O-44'5-000 Sff.a&
ice• 'fir
PLf614 C�2
tJANJ-�...-UMTOXAND
xi P?�i.:r-Plff) OM
50.00
U 02
amur 14 aTs,mow
CITY OF
�LA�eGLIM"rA
FY?'ZyhlVCE
RECEIPT
DATA /F.
BY --I
DAT FINE
INSPECTOR I
2
_
INSPECTION RECORD
4 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 Z - 2 - 2 Exhaust Fans
O.K. to Wrap C9 F.A.U.
Framing _ Compressor
Insulation �p Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wali Insulation Condensate Lines
Party Wall Firewall
Exterior Lath _
Drywall - Int. Lath
• Final
Finally O 2 C�—G POOLS - SPAS
BLOCKWALL APPROVALS 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 •�. yif �� Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans _ O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping
Gas Test U ; G
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)2-
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 �2 ✓b (y
Utility Notice (Perm)
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING CF -4R
w)
Firm:
Street Address: 15 iti1 W
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
ple Group Number
ple House Number
City/State/Zip: 2 � a k,& 6�f ! �
The house was: ❑ Tested r23- 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
ducts)
vrowhere 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)
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 AZ 114
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)
❑
ass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
PI -Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
❑
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