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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
ProfZssionals Code, and my License is in full force and effect.
License # Lic. Class Exp, Date
l - !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&RC. for this reason
Date c f- "t .' Signature of Owner ! r�
' ,..
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.
'( Y I have and will maintain workers' compensation insurance, as required by
Section tion 3700 of the Labor Code, for the performance of the work for which this
permlt,ls issued. My workers' compensation insurance carrier & policy no. are:
Carrier STA,5Kl;WID Policy No. 1 1
(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 WorkersCompensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees. '
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 1 Date L - �` • �" 3.
Is 6VILDING PERMIT PERMIT
DATE - VALUATION�T;fi���T11ri�1� LOT TRACT
JOB ADDRESSi��i{1.1�nsic�.tl':Zl��'l
APN -
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CAL- P.P.�:::EP-C: i3C}US
;S Y•6111:k:.Y.:F��.4:�'';fti�:f.i�;0:';?�'
�+��:rt5;r ;►3,A1et'F:s?,#1. ><�"S'�a:!��b, �:�.Uf�
LA ULIITA CA 9'7253
PA1,14 DRSWber CA 92711
aajl�h�: w7"d�%l C']14 6219
3�Fs-8�8�
USE OF PERMIT
T'�R1�,`.,i�i3
S5�yJ1ppliiypgpp�i'..'y1�y,e�$'U.!t�Fvv'a pfii7.. Yia$g ):$!}/C+d7�i.7ilh y.lt.�.:�9��yylit:�,7#T�,f:,.-
)9.1.:7`3.TLi'+te'3, DID fN 1, 9)�r�4a•fa,t'l,[ G`AIJa•i��! �:t•!;'L'a!'1 .� 1,e�T Ri�.r� t�r�1�+.
.R„CW)Pt, £� f rt4C1.,O LliI ldd:.T ]14P,% CiVD
3PA Oft•'!!@, �� )
aFrI&M' FRA rum"A.j. Y
PLAN 1°73101.0M. -3"9a318
CO2TS'C']lJC, i"TV_W. `ct` F 101.4100-1S 1'i-000 1�`$:s.00
Di41TtC RAMI,.•. , Hi"s 13001, 101 A0050-421-001) al -00
.
PLUNI4#MU FM • 7001.11 k01-0011-419.0070
e
APR 2 2 2003
CITY OF LA GUINTA
FINANCE EPT.
RECEIPT
DATE
BY
DATE Flr �y�
P T
INSR
44 ,13 - r,'
/t'.e j
S/5�l 03
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
'Sewer Lateral
Pool Cover
Seaver Connection
Encapsulation
17 1610 3
Gas Piping
Gas Test
Appliances
Final
p3
COMMENTS:
°, •.1,
r.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pale
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)
AUG -05-2003 06:18 AM
P. 02
CITY OF LA QUINTA
DING & SAFETY DEPARTMENT
r o
0,,!
F 03 777-7012
IN ECTION REQUEST LINE
�� * 777.7153
Wier `A HERN HILLS DEVELOPMENT
C t d _ _ CAl,r PAC,LFXC POOLS
t h umber 0304-335
POST ON JOB IN CONSPICUOUS PLACE
INSF ECTOR MUST_ SIGN ALL APPLICABLE SPACES
JOB AD )HESS 57-600 BALL'YBUNZON
PDOL, SPA, FIREPYt (496AGAL), BBQ (ANSI Z21 -58A -
CGA). ALARMS/BARRMRS SHALL BE IN PLACE AT PPJ
PLASTER INSPECTION, EQUIPMENT ENCLOSURE NOT
IPICLUDED
T(PE OF INSPECTION DATE INSP.
TEMPOR/,RY POWER
SMAC K5
FOOTING 3 / STEEL
CONCRETE SLAB
DCI NOT POUR CONCRETE UNTIL ABOVE SIGNED
ROOF NAIL / PRE -ROOF
OKAY TO NRAP
FRAMING COMBINATION
ROUGH ELECTRIC
I ROUGH PLUMBING
ROUGH MECHANICAL
INSULATION
COVER NO WORK UNTIL ABOVE SIGNED
INTERIOR GYP, BD. DRYWALL
EXTERIOF LATH
GAS TEST
MASONRY INSPECTIONS
i FOOTINGE: / STEEL
BOND BEIM
F OOL / SPA / WATER FEATU E 1)2S
PRE GUNI'"E SETBACKS q
U/G PLUM3ING . _ 1A
! ELECTRIC�IL y�'�"" Qly+ �
PLUMBING
MECHANICAL
PUBLIC WORKS DEPARTMENT
COMMUNITY DEVELOPMENT DEPT,
FINAL / JC B COMPLETED
am'q-1 03
1]
MCL C014CRETE FLAT WORK SHALL BE PLACED A
4INIMUM OF 2" An nw mirco aroecne
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
S 7 6 oe B4LL- ( E5Li kiI O�
Project Title
Project Address
di,i vez-iJELL 17&01485-5&SO
Builder Contact Telephone
Firm: DF=&mg-T Eh
Street Address: �.� •Zc�
Copies to: Builder, HERS Provider
"-g='r!1Mb -24-03
Date
KAAuLLA Cokj-ST
Builder N me
P LACLJ STo 14
Plan Number
�J-RoLiP# I
Sample Group Number
Sample House Number
HERS Provider: . N •�•IE .Q .
City/State/Zip: CAlJ4—t4y 11ZA4; i�Z?-7,
HERS RATER COMPLIANCE STATEMENT
The house was: 2 -'Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diai,nostic 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.
ET'The installer has provided a copy of CF -611 (installation Certificate.
CTI'Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
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.
12 MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurisation Test Results (CFM ct 25 Pa) values
Test Leakage Flow in CFM c> e)
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) 1r ❑
Pass Fail
L( THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑
provided for inspection Er
Ps-, Fail
ENERGYtoCADECSerWces
.
P.O. Box 621
Ph/Fax (760) 5642044
Rancho Mirage. CA 92270
Cell: (760) 835-7939
Email: RKrown6237@aol.com
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
S 7 6 oe B4LL- ( E5Li kiI O�
Project Title
Project Address
di,i vez-iJELL 17&01485-5&SO
Builder Contact Telephone
Firm: DF=&mg-T Eh
Street Address: �.� •Zc�
Copies to: Builder, HERS Provider
"-g='r!1Mb -24-03
Date
KAAuLLA Cokj-ST
Builder N me
P LACLJ STo 14
Plan Number
�J-RoLiP# I
Sample Group Number
Sample House Number
HERS Provider: . N •�•IE .Q .
City/State/Zip: CAlJ4—t4y 11ZA4; i�Z?-7,
HERS RATER COMPLIANCE STATEMENT
The house was: 2 -'Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diai,nostic 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.
ET'The installer has provided a copy of CF -611 (installation Certificate.
CTI'Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
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.
12 MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurisation Test Results (CFM ct 25 Pa) values
Test Leakage Flow in CFM c> e)
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) 1r ❑
Pass Fail
L( THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑
provided for inspection Er
Ps-, Fail
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
5-= 6 Ott E34 L_ ( E5 tJ Q I O
Project Title
Project Address
Jlri AyeAELL- (7 &c,) 485-5&S0
Builder Contact . Telephone
Firm: ®Emm—j:
Street Address: Be •640.0 42-I
Copies to: Builder, HERS Provider
—GE'- -tee -2 4- 0 3
Date
KA14uLLA (�okj-s-F.
Builder Nme
PLA� Cy 5'ro ►,I
Ian Number
g:�ev LIP
# r
Sample Group Number
LO -T- 0 01A,
Sample House Number
HERS Provider: . i •�•�.�
City/State/Zip:
HERS RATER COMPLIANCE STATEMENT
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.
13"The installer has provided a copy of CF -6R (Installation Certificate.
C11 Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
LJ 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.
L! 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 107
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 20090
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) 021, ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV)
In Yes ❑ No Thermostatic Expansion Valve is installed and Access is �/ ❑
provided for inspection �✓J
Pacc Fail
Deseft-
-
ENERGY ��t "'
C A D E C
S�� —
P.O. Box 621
Ph/Fax (760) 5642044
Rancho Mirage, CA 92270
Cell: (760) 835-7939
Email: RKrown62370aol.com
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
5-= 6 Ott E34 L_ ( E5 tJ Q I O
Project Title
Project Address
Jlri AyeAELL- (7 &c,) 485-5&S0
Builder Contact . Telephone
Firm: ®Emm—j:
Street Address: Be •640.0 42-I
Copies to: Builder, HERS Provider
—GE'- -tee -2 4- 0 3
Date
KA14uLLA (�okj-s-F.
Builder Nme
PLA� Cy 5'ro ►,I
Ian Number
g:�ev LIP
# r
Sample Group Number
LO -T- 0 01A,
Sample House Number
HERS Provider: . i •�•�.�
City/State/Zip:
HERS RATER COMPLIANCE STATEMENT
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.
13"The installer has provided a copy of CF -6R (Installation Certificate.
C11 Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
LJ 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.
L! 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 107
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 20090
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) 021, ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV)
In Yes ❑ No Thermostatic Expansion Valve is installed and Access is �/ ❑
provided for inspection �✓J
Pacc Fail
Desen
ENERGY CADEC
s '
tw� - ,
P.O. Box 621
Rancho Mirage, CA 92270
Email: RKrown6237@aol.com
Ph/Fax (760) 5642044
Cell: (760) 635-7939
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page_) of 7) CF -4R
5 7 6 oo E3,!%1 -L-( 6 L q otJ
Project Title
Project Address
div,Ave,JELL- (7�oJ �F85-S�so
Builder Contact Telephone
r COO) U_ 7 -
HERS Ra.e Telephone
Certi ng Sig ature Date
Firm: DESA tT
Street Address: f.0 -8 .40
Copies to: Builder, HERS Provider
Date
KAI+u LL A eo U
Builder Nme
PLA � �f—'tJSTOr"1
Ian Number
�iR,5,IlP
Sample Group Number
Sample House Number
HERS Provider: • ! •�•1 • Q -
City/State/Zip:
HERS RATER COMPLIANCE STATEMENT
The house was: ❑Tested 13 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.
/The installer has provided a copy of CF -6R (Installation Certificate.
In"Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
CWhere 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.
12( MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured r
Duct Pressurization Test Results (CFM ct 25 Pa) values
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here pj�e7
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
YTHERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑
provided for inspection u
pact Fail