0107-213 (SFD),y 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
Date Vj' Signature of Contractor •^'f
OWNER -BUILDER DEC; ARATION
I hereby affirm under penalty of perjury that 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:
O 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.
(K) -I have and will maintain workers' compensation insurance, as required by
Sen 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:
Carver Policy No.
L2:1.KIMPT
(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 sous 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: r, � ~ � Applicant . ,%%r�'.
`Warn'ing: Failure to secure Worker ' 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 i
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.
Signature. (Owner/Agent) %'+`-> Date4-
---4' P"f
BUILDING PERMIT PERMITN \
DATE fJVALUATION d LOT
J
[ 0107-9.113 TRACT ?fig, 7
1 (¢(g qyK yry t <
� I t• 1�Ab173 AF&}w�uA✓G9 S J Wa 4
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
47 -75 0 ADA t'R k f978
47.7511 A.).A.W, DIRK "OU
A Q�li€3 �i CA5
'LA Q�J�J`�`A Cid,. 9225"s
(760)564-1/820 CYBIJO 02W
USE OF PERMIT
/
wn) , mAnir.R. 02. P�?12f�413' DatCti wo'1' Yl3C?..R.:um. ";iI.DuK
{mA.I.1sury
W.e�.fai'iagy P00A,RS➢£ A CA SJd'nIVEW�4.Y A:P.P1Z.OACH,
STZ3AC.1' C:(MN` UCTION .'3''i oo S
PO LC°HdPATIO 40.00 SIP
Wkt MKI�AT.Q.YORT At33.po OF
S FT. 'WOOD VENCE 200.00 'up
a4 Zl? %c� U9Z' C`Cy lo►9: ui7 kfi�i�
108"Z 20
Cd;�t1I1� 1Z6JC�7'ZC3� �`%�, l CsZ �4�"t0€�t� 4f•G043 SO'P1,4?fA
;?ffdA�i d�'•)E�.��':h: Il`k:1P• 3. CE1-1p�(;1..4:'1.�� � 1 �3 fg34Ci.15
MECHANKII iL Fag $62100
1YLXTR,ICAJ, YL+1': 101-000-420,41,00 $120.94
1111UZIA11OFf , 101,-0041=419.000 1122;75
xTl:til CI AP10TION 1;' IE • RUDD 101-•4700-2A1-•4)00 $10.29
GRAIDT 0 ,MV, 220,00
DA'*, '9AZA'9t, IMPACT PEP, $1,9in.00
MWASE PLAN 101.000"441-.345 V4?c+ ao
FIE DEa"?Clfx1't
Z� ' AN E,':FS:
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
Framing / �'!'!�d
F.A.U.
Compressor
Insulation _ ���
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 z-7— d
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 /Ols�O/ Si
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
_
Sewer Connection �Q�s/Q/ 5f '
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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) �.,p
Notice:
Document Cannot Be Duplicated
Date 8/29/01
No. 22425
h
Desert. Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameRandv & Sharon Bills .
No. 51-950
city La Quinta
Street Avenida Rubio
Tract # BL 34 Lot # 15
Type of Development Single Family Residence
Comments
' APN # 772-162-010
Jurisdiction La Quinta
Permit # 0107-213
Zip 92253
Log # `
Study Area
Square Footage 1788
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: .
EXEMPTION NOT APPLICABLE }
This certifies that school facility fees imposed pursuant to
Government Code 53080 in the amount of
Y
the property listed above and that building
t
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: .
EXEMPTION NOT APPLICABLE }
This certifies that school facility fees imposed pursuant to
Government Code 53080 in the amount of
2.05 X 1,788 or $ 3,665.40
the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now -,be issued L
Fees Paid By CC/EastWest Bank - Sharon Bills
Telephone 760-564-7820
Name on the check
By Dr. Doris Wilson
Superintendent
SZr; .:
Fee collected /exem ed by Annette Barlow
Payment Received $3665.40
vw'� 6, L"`
Signature
Check No. 2340645 +
IOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
bove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
ollect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting `
21.3
c(O?'
Building
Address ✓ ✓
4
"
TAtyl
P.O. BOX 1504
78-495 CALLE TAMPICO'
f--)jaLAQUINTA, CALIFORNIA 92253
Mailin
Address,
City / U � /v 1 IVt ` lZip�J
Contractor /
C 146"v
Add-- s
tVl y( //LT4 ZI&I t t� �—� Te,77_, 3 /
State Lic- City
& Classif.�� Lic. #���
Arch., Engr�., /
Designerj�y
Address V Tel C� %
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licen�s��0d under provisions of Chapter 9 (commencing with Sec ton
7000) of Division 3 bf th_B
Btistn�ssand Profe sign's.Cdde, and my license is ' f f orc apd
effect. �' ///
SIGNATURE / f / DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5.Susiness and Professions Code: Any city or county which requires a
permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for thealleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
E., 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
I7 I am exempt under Sec. -•B^& P.C. for this mason
Date a /!Owner��•''��
WORKERS' COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. - Company
n Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify thai in the performance of ing 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.
Date Owner
NOTICE TO APPLICANT., d, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives�sof-this city to enter the above-
mentioned property for iin/nsp6cct�tii/f', pbrposes- ��/.r�G" f
Signature of applicaV�/i1/il .J__.,.� Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST
if
Y'
plads
APPLICATION ONLY
OCC. GRP.
A.P. Number / / 0 /& Q r Q/ Q C/
Legal Description
Project Description _VA46c/ F 71111%t
Si /f e t 12 Sto
No. Dw.
Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech. r
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
07/12/01 THU 13:35 FAX 909 889 7632 CONTRACTORS FINANCIAL Q002
Juin- 1F3-01 12:35P RE/MA: >f the Desert -La q
P. 02
CALIF 6 ;NIA VACANT LAND PURCHASE AGREEMENT 51-950
A s s o c f i 1' l o N AND JOINT ESCROW INSTRUCTIONS / AvE' R U 6/ O
0F ILEAL :IRSa
(AND RECEIPT FOR DEPOSIT)
(C.A.R. Form VLPA-11, Revised MCI)
Date_ .r+n. ss, ?oe at
..,
1. OFFER
California.
A. THIS IS AN OFFI t FROM �n (i' - et �!!
�r�
B. THE REAL PROs :RTY TO BE ACQUIRED is descn
--'�"'
„
d asit I! Hix JI AVENtaa ltUDIC
__
Assesso!' Parca loW 773-762-01p --V/--
_ _ ••„_�
_
_rte
I QvI.Kt A _ . County Of _-......
HE
C. TPURCHASE 'R(CE offered is lyenty-si.. 77xanriand RSv�u9t!>r ,
situated in
alifornia (-Property)
D. CLOSE OF ESCF IW S occur _Davi After. AaeptsncOoltars S Riot
2. FINANCING: 4 (Or on
_ oo
00 (date)).
O ifige n the loans below 4 a wntsrlgeFICY of this Agreement unless:
Buyer shall act d'digent and to good (ai1t1 to obtain the ttesigneled ba(i) atther 2D or 21 a checked below o
:0 otherwise eyreed.
ns. Oblatning deposit, down payment and closingcosts
A. BUYER HAS GIV V A DEPOSIT TO THE AGENT SUBMITTING THE OFFE
for to p ). made Payable to s
—
f' `.�
rhos a corrtln
Y'
_
- --
Check, or Y P / Eetri7�oy Personal
deocaded .whin 3 iutdrsevewhich shall be held uncashed until Acceptance and then
days aflerAueptanae or
-1
U wxh Escrow t lieu, [J into Brokers trvsf account. at QQ 1/2`00„ACG7W7aNd
Buyer represent:. at funds will be good when deposited vrb Escrow'HolO
r,
B. INCREASED DEF W shat) be deposited by Buyer with Escrow Holder w”
or ❑ D"1111 After A006plance. S
_
C. FIRST LOAN IN T E AMOUNT OF .--
, . , , • , , , , •
[] NEW First De I of Trust rn favor of 0 LENDER, [] SELLER, i
OR ❑ ASSUMF' ON of Existing First Deed Of frust;
encumbering the' *petty. sewring a note peyebls due ❑monitliy, [)puarteAy, [jsemi-annually. ❑ annuauy at
maximum Inter" I
76 fled rale, or %initial adjustable rote with a maximum lifetime interest
rete cap o1 _ !b- balance due in
Mean, anfolued over
interest -only lista' nerals). Buyer shell pay torn fief Years (or [] (if Cflerlted) payable in
D• ❑ ALL CASH O 'ER: (H Checked) No loan b weeded to
purchase the pro
perty. Buyer &host. writhin Days After Accep nce, provide Soler written verification or sufrreiont funds close tttia tranaaclion BellerDmay canoe!
this Apfoemerit
it rleng within 6 Days After (Q time to provide verification OXOIMS, if Buyer fails to provide verification or
(ii) receipt of vent upon, N Salter reasonably dicappreves it.
E. ADDIT"ALFIN NCINGTERMS:
F. BALANCEOF V1J CHASE PRICE (not ineludfry costs of obtaining loans and other closing coals) to be deposaed wqh S 2,t q00
Escrow Holder wn. 1 suffiViOnt tars* to nose escrow. -
O. TOTAL PURCHAt i. PRICE ... . .
H. LOAN CONTINGE CY shall remain in affect until the dosignaled bans ore funded or assumption o1 exialing financing is d (o[� r prover000 00
Days af(sr Accept Ice, by "Ich time Buyer shall give Seller vssten robe* of Buyer's ebet100 to cancel this Agreeniter it Buyer is unable to
obtain the deegnc d loans. if Buyer doss not give Seller such notice, the contingency of obtain" the designated loan shall be removed by
I
ie method sperlfr , I in paragraph 1s)
I' r' NO LOAN CO TINGENCY: (If checked) 0018 an foan to
this (ring Y paragraphs ?C, 2E, or eteewRere in Ibis Agreement Is" 10T a contingency of
Agrneement. If Oyer does not obtain the loan(s)- and as a Mutt Buyer does not purchase the property, Seller may A entitled to 0uyees
deposit or other Its. 1 remedies.
The copyright laws of the I tiled States (Title 17 U.S. Code) torW the Buyst and Seller acknowlegils receipt of a copy of the )age,
unauthorYaed reproduction rel 111 form, of any potion Ihereof, by photocopy
machine or any other mean, tncfuding facsimile or computerised 1*rawls. 6uWa Initials ( �I
Copyright 01996.2001, CA FORMA ASSOCtAT'tON OF REALTORS®. Sellars initials
INC. ALL RIGHTS RESERVI I. ) e`a"teanrm�
VLPA-1 f (PAGE 1 OF 8) Reviewed or —j
f roket a Dealprwe ` Date 'J(
VACANT LAND PURCHASE AGREEMENT (VLPA41 PAGE 1 OF a)
RLMAx Real Hetue Contulra. 70(-4 11 Hw> I11. 1.0QuuneCA 9ZI53
Phonr 7htl.Fad-t 188 104 760.3(.4.8177 Re/Max Rent Estate L'0nsul4ntr i•'
T61 aura to .
I
ZO'd b el-l.aasa0 40 XHW/321 d9C=C0 LO-TZ-unC-
07/12/01 THU 13:36 FAX 909 889 7632 CONTRACTORS FINANCIAL
OLD REPUBLIC TITLE COMPANY
ORDER NO. 518592-1
The land referred to in this Report is situated in the County of Riversides City of La Quinta
State of California, and is described as follows:
Lots 15 in Block 34 of Unit $2 of Santa Carmelita at Vale La Quinta, in the City
of La Quinta, County of Riverside, State of California, as per map recorded in
Book 18, Page(s) 55 and 56, of Maps, in the Office of the County Recorder of
said County.
31
Page 3 of 6 Pages
Z003
07/12/01 THU 13:37 FAX 909 889 7632 CONTRACTORS FINANCIAL
Jtarl- 1J-01 03:.15P FqE/MAX -)f the Desert -La Q
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RC DISTRICT - PLANNING REVIEW FORM
This. form is to- be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house design does 'not duplicate the same architectural style of any
house within 200 feet of the applicant, and/or 2) if there is a need for the applicant to file for
Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please
transmitted this information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT
LEGACY HOMES
SITE ADDRESS 51
APN 772 _ 162 - 010
LEGAL: LOT 15
-950 Avenida Rubio `.
CASE NO.: 20017521
BLOCK, 34 UNIT
S.C.@V.L.Q.
CHECK AND APPROVED BY: Fred Baker DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary maintains 'a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Verify legal and APN information
Consistent with MDG on file (as
applicable
`7
MDG filing required (5 filings since
9/3/98)
Architectural variety within 200 feet of
the surrounding area:
Colors
Materials
Architectural design features
AP
ROVED BY COMMUNITY DEVELOPMENT DEPT
E
Al
IT
Other Requirements:
P. O. "BOX 450 *,LA QUINTA * CALIFORNIA,* 92253-0450
760/564-1866 * FAX 760/564-2627
Certificate of Occupancy
City of La.Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use.. For the following:
BUILDING ADDRESS: 51-950 AVENIDA RUBIO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0107-213
Occupancy Group: R-3, U-1 Type of -Construction: VN Land Use Zone: RM 17/1
Owner of Building: RANDY & SHARON BILLS
Address: 47-750 ADAMS STREET #278
City: LA QUINTA CA 92253
By:
�d Date:
e
Building Official
POST IN A CONSPICUOUS PLACE
KIRK KIRKLAND
FEBRUARY 7,2002
JOB ADDRES� CITY OF LA QUINITA SUB -CONTRACTOR LIST
S. � � �
PERMIT NUMBER _
__ ow�iER--12= '�J �___r ► �-S _. __ euf�FFa_ lel. L�+C�� ��YY► - - -
�r : this luh. Any ch�� on i_thg giplldbw In '� �� � all tinea " a n _
rages to this list must be approved by the guild' Division J� 11 '-'�' Only persons appearing on this list or their employees are authcxited to work
b!jildi;ig permit. For each ap icable trade, all information requested W. ow must be e 10 emdeted b nappficanit of �• 'On �File' lure t s not an acceptablely will r estAt 'r a o �sloppaf3c of t c�rfc acrd/or oaar�c.e
iL Trade / cbasilr«xctian — -
..........
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:INSTALLATION CERTIFICATE
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Yernut Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
❑ DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM @ 25 PA)
Test Leakage (CFM) %y
Fan Flow
If Fan Flow is Calculated as 400 cfin/ton x number of tons, or as 21.7 x Heating Capacity
in Thousands of Btu/hr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction <_ 0.06
❑ For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
❑ Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections
❑ THERMOSTATIC EXPANSION VALVE (TXV)
CF -6R
0— ❑
Pass Fail
❑ ❑
Pass Fail
Yes • ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection 0 ❑
Yes is a pass Pass Fail
❑ DUCT DESIGN
I ❑ Yes ❑ No ACCA Manual D Design calculations have been completed,
Duct Design is on the plans and duct installation matches
plans.
2• ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -1R. -
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2 is a Pass Pass Fail
❑ I, the undersigned, verify that the above diagnostic test results and the work I performed associated with the test(s) is in
conformance with the requirements for compliance credit. [The builder shall provide the HERS provider a copy of the CF -6R
signed by the builder employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for
compliance credit.]
Tests Signature, Date
Performed
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
January 4, 2001
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name)
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