0211-211 (SFD) (2)`,•,;,: LICENSED CONTRACTOR DECLARATION
i;
..� * •;I-.hereb 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
WProfessionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
,�
r --LU �P $t. iii 81 C100'C s 1/04
o Z Ir Date i� Signature of Contractors - - -
'
ip OWNER -BUILDER DECLARATION
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
oZ I hereby affirm under penalty of perjury one of the following declarations:
U') 1.—O () 1 have and will maintain a certificate of consent to self insure for workers'
X W 4-- compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
a rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT Z Carrier M,EI PT Policy No.
obn
I- O
J .,(This section need not be completed if the permit valuation is for $100.00 or less).
1(�=) I certify that in the performance of the work for which this permit is issued,
Iishall 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' r�r
Date: 'm) ` 7' Applicant
� � !1
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
q 1 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
i.. 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 Ithis City to enter upon
the above-mentioned property for inspection purposer
�"'§ignature (Owner/Agent.'~ for,
s �� Date
BUILDING PERMIT PERMITk
DATE VALUATION LOT TRACT
4M55SZ0 29 29147-1
JOB SITE
ADDRESS .57-&W VALLYBUM0
APN * it
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WH19KOP
itc+ W0 MAmaclvii
?E1aU7{1 CKRA a
]:,A WT3.9?.TrA, CA 92253
i.F.Q1:3N'3 & CA X253
Md� 3237
USE OF PERMIT
M-4 F.At, aly 33WELT .11 G
spr) e liar 2o, PtAwX11. PZRPAIT :1.100 NOT INCLI.3DI? BLOCK WALIZ,
POOL, OTR Ia.Ik37MA`Y' .A.PP€ OA,CK 15% 1 910'OUNT TO 1'faAN CHECK V E
009 TO MU1MPLZ :ISS"1Y.A NCZ OF SAME PLAN TYPE:
CUISTOM CCS?FO'!`RUCTION 4,869.0 OF
PORCHsPATIO ,� 1,156.00.,w
GARAC-MCARI PORT 8! 1.00 OF
EY -F #dIAM VOST OF CUN.W.RU :' ON
410; : t
tr'W�} .1'' it ER AT MAR
WNSTRUCTION FEE 101-000.438.000 T!S'Y'a8100
Safi. N CHECK M 101-�+0 4,39-318 1350.12
MEC:1'U-MC':IAL FM 101-000.421-000 .144 9X
LEC, TRICAL, YZE '101-00"20-000 �s. & M
PI,tJP, BIND ME 101-000-419-000 32153.")s
STRWN0 MOTION rUZ - READ 101.-.000-241-000 $41.06
OFLADI'ric'r FEE 101-CIOO-42.3-000 $,01.00
1C5WktLOOPFUR IMPACT A22, 42,405.Otl
ART 04 PUBLIC PLACE'S - KESM 270-00.7.445-000 SS26,41
$5,725.48
ffm-"
$0.00
c �; . Pkr1ffs V1.919 ME NW
$5,7215AS
DEC 1 2002
CITY OF LA GUINTA
FINANCE DEPT.
RECEIPT
DATE/
BY
D FINA �/�
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
ReturnAir
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
_Y fY1
F.A.U.
Framing
it 6 2 A
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
BLOCKWALL APPROVALS
Final —
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
/��1�
Heater Final
Water Piping
Plumbing Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
��03
Pool Cover
Encapsulation
Gas Piping
Gas Test
oe_
�� b
Appliances
Final
COMMENTS:
Final
Utility Notice {Gas}
ELECTRICAL APPROVALS
Temp. Pourer Pole
Underground Conduit
Rough Wiring / i3
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
r Utility Notice (Perm)
ENERGY "' G A 0 E C
Se rvims -
P.O. Box 621
Rancho Mirage. CA 92270
Email: RKrown5237@aol.com
Ph/Fax (760) 564-2044
Celt: (760) 835-7939
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
51 6,01'o E34,LL ( 6v CJI o ij
Project Title
I�a Qty I N
Project Address
aJlr� /tyE►JELI_ 0&c,) -fO5-5&S0
Builder Contact Telephone
®_
HERS Rater Telephone
e
Certi ing ignature Date
Street Address: E® <-g
Cooies to: Builder, HERS Provider
--fks-Fm D 7 —;Z4-- 0 3
Date
KAOuLLA eokj-5
Builder N me
�y 5To►�4
Man Number
6 024 P 1 0 3
Sample Group Number
L47-7- * 0A
Sample House Number
HERS Provider: . •�•(�. Q S .
City/State/Zip:
ITERS RATER COMPLIANCE STATEMENT
The house was: 53"Tested ested ❑ 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 compllance requirements as checked on this form.
The installer has provided a copy of CF -611 (Installation Certificate.
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. rubbee adhesive duct tape to seal leaks at duct connections.
LJ 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 4-1
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here �jjo0
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
THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
9/ ❑
Pacc Fail
0,
' \
ENERGYeCA8EC
��c
P.O. Box 621
Rancho Mirage, CA 92270
Email: RKrown6237@aol.com
Ph/Fax (760) 564-2044
Cell: (760) 835-7939
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
51-690 641-L--( by Ql o k ]
Project Title
Project Address
J I '1A vEijELL 0&-) -85-5&50
Builder Contact Telephone
HERS
Telephone
Certing S gnature Date
Firm: DEIart.-r EdI %
Street Address: f!-® •a"OZc tegj
Conies to: Builder, HERS Provider
-'A � 0 M e—2q--03
Date
KAI4uLLA eokj--),
Builder N�tt�me
SLA �I CtJ STo NI
Plan Numb
':5iRV r
Sample Group Number
L47 -r *- X14'
Sample House Number
HERS Provider: • •�•�<Q
City/State/Zip: CAL]e— &o � .A -0)=76
HERS RATER COMPLIANCE STATEMENT
The house was: 93 -'Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing dia;,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.
,/The installer has provided a copy of CF -6R (installation Certificate.
C!,,/ Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
U 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.
Ed 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 O�
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 200 O
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) = S • 2 S °%o
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fail
L'7 THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is �% ❑
provided for inspection (�j
Paec Fail
Desert e-
P.O.
ENERGYCADECs��
Box 621
Rancho Mirage. CA 92270
Email: RKrown6237@aol.com
Ph/Fax (760) 564-2044
Cell: (760) 835-7939
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R .
51-690 641L_ ( e)u wl o�J
Project Title
Project Address
Jl,1 vE►-JEELL-- (7&0) -"5-5&50
Builder Contact Telephone
HERS
Telephone
Certify ng Signature Date
Fin-: DEsee-r E.d if ;�t6e.Vae-eS
Street Address: PC' •F&O-A (ezo
Conies to: Builder, HERS Provider
03
- om: 7-24-0 3
Date
KAI4uLL A eo kj-5-f.
Builder N
me
LA r� Cy 5'(o '4
!an Number
av P -343
Sample Group Number
L45- r * 0/4,
Sample House Number
HERS Provider: �' • •�•�•Q
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.
CT'The installer has provided a copy of CF -6R (installation Certificate.
U.,/ 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.
Ed 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 o lb
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 2.0,00
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) = S.
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fail
3 THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is❑
provided for inspection
Pacc Fail