BMCH2017-0022LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapt&,
9 (commencing with Section 7000) of Division 3 f the Business and Profession_ s Code,'
and my License is in full force and effect.
License Class: C20, C36 License No.: 777 4 `
1
Date. Contractors
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that lam exempt from the.Contractor's State
License Law for the following reason (Sec. 7031:5, Busines' and Professions Cade: Any
city or county, that requires a permit -to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to.file a
signed statement that he. or she is licensed pursuant to the provisions of the,
Contractor's State License,Law.(Chapter,9 (commencing with Section 7000) of.Division
3 of the Business.and Professions Code).or that he or she is exempt.therefrom and the
basis for the alleged 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).: t .
I_)_I, as owner of the property, or my employees with wages as their sole
J
compensation, will do the work, and the'structure isnot intended or offered for'sal
(Sec. 7044, Business and Professions Code: The Contractors' State License.Law does
apply to an owner of property who builds or improves thereon, and who does the w
himself or herself through his or her own employees; provided that the improveme'. s
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 or she did not build or improve for the purpose of sale:).
(_) I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves,
thereon, and who contracts for the projects with a contractors) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B.&P.C. for this reason'
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'
pensation as provided for by Section 3700 of the Labor Code, for the performance
of the wor or which this permit is issued.
1 have and will maintain workers'.compensation insurance, as required by
Sectlon300 of the Labor Code, for the performance of the work for which this permit.
is issued. My•workers' compensation insurance carrier and policy number are:
Carrier: MIDWEST EMPLOYERS CASUALTY COMPANY Policy Number:
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in manner so as to become subject to the workers'
compensation laws of California, and agree that, if should become subject to the
workers' compensation provisions of Section 370 of the Labor Code, I shall forthwith
comply with those provisions.
Dat E/ . 1 � Applica t:
WARNING: FAILURE�TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
e. ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
not COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
ork INTEREST, AND ATTORNEY'S FEES.
nt
Date: Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a'construction lending agency for
the performance of the work for which this perniit.is issued (See. 3097, Civ. C.).
Lender's Name:
Lender's Address:
APPLICANT -ACKNOWLEDGEMENT.
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta; its officers, agents, and
employees for any -act or omission related to the work being performed under or
following issuance of this permit.
2: Any permit issued as a result of this application becomes null and void if work is
not commenced within 18U 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 istat
formation is correct.
I agree tolcomply with all city and county ordinances arelating to building
construction,.and.hereby authorize representatives ofter upon the
abo em nti ned'property for inspection purposeste• Signature (Applicant orggen
KUU�I/
VOICE (760) 777-7125
78-495 CALLE TAMPICO
FAX (760) 777=7011
LA QUINTA, CALIFORNIA 92253
DESIGN-& DEVELOPMENT..DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING'PERMIT
Date: 2/6/2017
Application Number: BMCH2O17-0022
Owner:
Property Address: 54785.AVENIDA R'AMIREZ
RICK HURT
APN: 77429501'4.'
z
54785 AVENIDA RAMIREZ
Application Description: HURT/ CHANGE OUT (1)HVAC SYSTEM
LA QUINTA, CA 92253
Property Zoning:
Application Valuation:. $8,400.00
i.
cs
D N
Q
z o
= z.
Applicant:®
S o
Contractor:
J ANTHONY PLUMBING HEATING & AIR CONDITI
00
J ANTHONY PLUMBING HEATING & AIR CONDITI
72216 NORTH SHORE ST #101
U
v
22216'N6RTH SHORE ST 6101
THOUSAND PALMS, CA 92276
THOUSAND PALMS, CA 92276
(760)32&8096
Llc. No.: 777794
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapt&,
9 (commencing with Section 7000) of Division 3 f the Business and Profession_ s Code,'
and my License is in full force and effect.
License Class: C20, C36 License No.: 777 4 `
1
Date. Contractors
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that lam exempt from the.Contractor's State
License Law for the following reason (Sec. 7031:5, Busines' and Professions Cade: Any
city or county, that requires a permit -to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to.file a
signed statement that he. or she is licensed pursuant to the provisions of the,
Contractor's State License,Law.(Chapter,9 (commencing with Section 7000) of.Division
3 of the Business.and Professions Code).or that he or she is exempt.therefrom and the
basis for the alleged 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).: t .
I_)_I, as owner of the property, or my employees with wages as their sole
J
compensation, will do the work, and the'structure isnot intended or offered for'sal
(Sec. 7044, Business and Professions Code: The Contractors' State License.Law does
apply to an owner of property who builds or improves thereon, and who does the w
himself or herself through his or her own employees; provided that the improveme'. s
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 or she did not build or improve for the purpose of sale:).
(_) I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves,
thereon, and who contracts for the projects with a contractors) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B.&P.C. for this reason'
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'
pensation as provided for by Section 3700 of the Labor Code, for the performance
of the wor or which this permit is issued.
1 have and will maintain workers'.compensation insurance, as required by
Sectlon300 of the Labor Code, for the performance of the work for which this permit.
is issued. My•workers' compensation insurance carrier and policy number are:
Carrier: MIDWEST EMPLOYERS CASUALTY COMPANY Policy Number:
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in manner so as to become subject to the workers'
compensation laws of California, and agree that, if should become subject to the
workers' compensation provisions of Section 370 of the Labor Code, I shall forthwith
comply with those provisions.
Dat E/ . 1 � Applica t:
WARNING: FAILURE�TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
e. ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF
not COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
ork INTEREST, AND ATTORNEY'S FEES.
nt
Date: Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a'construction lending agency for
the performance of the work for which this perniit.is issued (See. 3097, Civ. C.).
Lender's Name:
Lender's Address:
APPLICANT -ACKNOWLEDGEMENT.
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta; its officers, agents, and
employees for any -act or omission related to the work being performed under or
following issuance of this permit.
2: Any permit issued as a result of this application becomes null and void if work is
not commenced within 18U 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 istat
formation is correct.
I agree tolcomply with all city and county ordinances arelating to building
construction,.and.hereby authorize representatives ofter upon the
abo em nti ned'property for inspection purposeste• Signature (Applicant orggen
Application Number:. BMCH2017-0022
Property Address: 54785 AVENIDA.RAMIREZ
APN: 774295014
Application Description: HURT/ CHANGE OUT (1)HVAC SYSTEM
Property Zoning:
Application Valuation: $8,400.00
Applicant:
J ANTHONY PLUMBING HEATING & AIR CONDITI
72216 NORTH SHORE ST #101
THOUSAND PALMS, CA 92276
Date: 2/6/2017
Owner:
RICK HURT
54785 AVENIDA RAMIREZ
IA QUINTA, CA 92253
Contractor:
J ANTHONY PLUMBING HEATING & AIR CONDITI
72216 NORTH SHORE ST #101
THOUSAND PALMS, CA 92276
(760)328-8096
Uc. No.: 777794
-------------------------------------------------------- ------------------------------------
Detail: HVAC CHANGE OUT - 14SEER/81AFUE SPLIT SYSTEM [2016 ENERGY) CARBON MONOXIDE ALARM(S) TO BE INSTALLED PRIOR TO FINAL INSPECTION.
2016 CALIFORNIA BUILDING CODES.
u
.. .4 :. �. i.. a.s...a .. ... yr v .. ..i.. •. ... w'..: .L. :.
'� . �. .1 ..
DESCRIPTION'
ACCOUNT.'
QTY
AMOUNT
BSASSB1473FEE`-, `:.
101-0000-20306
0
$1.00
nTotal Paid for BUILDING STANDARDS ADMINISTRATION BSA:
$1.00
.
DESCRIPTION
.''ACCOUNT
QTY
AMOUNT
'
HVAC CHANGEOUT -SPLIT SYSTEM
101-0000-42402 '
0
$76.00
DESCRIPTION;`
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$38.00
.Total Paid for CHANGEOUT:
$114.00
DESCRIPTION
-` ACCOUNTQTY
AMOUNT
"
PERMIT ISSUANCE101-0000-42404
r
0
$96.27
>
Total Paid #or PERMIT ISSUANCE:
. M,
$96.27
g.
S
r
Bin #:,:-
...t.;; t:
T*Cray of I.a Qwnta
Building &r Safety Division .
P.O..Box.1504, 78-495-Calle Tampico
La Quinta, CA 92253- (760) 777-7012
Building Permit Application and Tracking;Sheet
Permit #
Project Address: 7U . rTti'Q/a 1JNr . 2 �-
Owner's Name: \0.J
A. P. Number:
Address:
Legal Description:
City, ST, Zip:
Contractor:
— /
Address: J ANTHONY SERVICES
Project Description:
City, ST, Zip: THOUSAND PALMS CA 92276
TW
Telephone:
<>a
State Lic. # : 11
CityLic. 9... lv oq.r..
Arch., Engr., Designer:
Address:
`
City., ST, Zip:
Telephone:
:':;; : < "'::'::' :"'` :`": "''"`
:.iil:;�y.: � �: iirnii:.l.4i' ii:!:•i:??vii:::?
Construction Type: Occupancy:
L c. #
r ProJ'ect tYPe �cit leone):' New Add'n Alter Repair DemoState
Name of Contact Person:'PA
n
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: W 143
Esiimated Value of Project: v�
;APPLICANT: DQ;.NOT WRITE BEL0IN,THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for. corrections
Plan Check Deposit
Truss C21Cs.
Called Contact Person
Plan Check Balance.
Title 24 Calcs.
Plans picked up
Construction
Flood plain pian
Plans resubmitted
Mechanical
Grading plan
2°" Review, ready for"corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked -up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:
'"' Review; ready for corrections/issue .
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
CERTIFICATE OF COMPLIANCE
CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT -HVAC) (Page 1 of 3)
Project Name: HURT Date Prepared: i 2017-02-06
A. General Information
CF1R-ALT-02 is applicable to multiple space conditioning systems contained within a single dwelling unit. When multiple dwelling units must be documented, use one
CFIR-ALT-02 doc6ment for each dwelling unit.
01
Project Name
HURT
02
Date Prepared
2017-02-06
03:
Project location
5.4.785 AVENIDA RAMIREZ
04
Building Type
Single family
05
CA City.
La Quinta06
AA,
.Dwelling Unit Name
HURT
..
07
Zip.Code
92253
08
Dwelling: Unit Conditioned
2 .,
1600
i
j
i : '
':
r
Floor Area(ft )
SC System
SC System
"CFA served
system a
refngeraht=
Installing new SC.
Installing
Installing '
Installing
Identification or
Location -or
by this SC
NumbertofP
S ace
containing
09
Climate Zone ..
Y
15 b
to
Conditionin SG ;S stems in
1
Served
System (ft2)
?
component?
this Dwelling Unit:
feet of ducts?
duct system?
SC system?
...�. •tet _ z.�..�:. :u�,s, ,�,. ,.�,�o
-_..__
B: Space Conditioning (3C) System Info
r
-. xmation
low �`
: R.
04 -;.
X05
07
O$
09
10
.03.
AA,
.frisk. t�!.+%,'r_
_ .. iuJ'. !tA
..
.sr^ia•
Is the SCS`
Installs ga
i : '
':
`�
SC System
SC System
"CFA served
system a
refngeraht=
Installing new SC.
Installing
Installing '
Installing
Identification or
Location -or
by this SC
ducted.
containing
system
more than 40I
entirely, new
entirely,new
`Name
Served
System (ft2)
system?
component?
components?
feet of ducts?
duct system?
SC system?
Alteration Type
y System 1
Location 1.
1600:
Yes
Yes
Yes
No
No !
No.
Altered space{
conditioning system
C. Extension.of Existing Duct System, Greater Than 40 Feet (Section150.2(b)1biib)
This section does not apply to this project.
i
Registration Number: 217-A620039695A-600-000-0000000-0000
CA Building Energy Efficiency Standards - 2016 Residential Compliance
Registration Date/Time: 2017-02-06 09:55:43
Report Version: 2016.1.005
Schema Version: rev 10/16
HERS Provider: CaICERTS
i
Report Generated: 2017-02-06 09:55:46
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT HVAC) (Page 2 of 3)
D. Altered Space Conditioning System (Sections 150.2(b)lE and F)
i
01
02
03
04
05
06
07
08
09
10
11
12
Heating
Cooling
j
System
Heating
Altered
Heating
Minimum
Altered
Cooling
Minimum
I Required
New or
:Identification
System
Heating
Efficiency
Efficiency
Cooling
Cooling'.
Efficiency„
Efficiency
Thermostat.
:Replaced
New Duct
or Name
-Type.
Components'
Type
Value
System Type
Components
Type
Value
I Type
Duct Length
R -Value
System l
Central gas
furnace
Gas furnace
AHU
AFUE
81
Central split
AC
Outdoor
condensing
SEER
14
i
i Setback
This field or
section is not;:
This field or
section is not
unit
applicable
applicable -.
Reauired Documentation:
CF2R MCH -01-E Space Conditioning Systems., -
Duct
I
i
- insulation requirementfor the new portions of suppler and return -air ducts or,pienums: R6 (CZ 1-10, -12 and;13) and R8 (CZ 11 and 14-16)
CF2R and CF3R MCH;20 H - Duct Leakage Test.required when.heating or cooling components are installed inducted_ systems, or when more than 40
ft of duct length is replaced
-Leakage rate compliance: <=15% or <_ 10% leakage to outside�,or seal,all accessible leaks.
CFZR and CF3R MCH=25-H Refrigerant Charge verification requ�ir'ed when refrigerant containing components are installed or altered (applicable in CZ
2'8-15).
CF2R and CF3R=MCH-23 Airflow Rate > 300 CFM perrtoh�reg61 ed,,whe, MCH 254is required.
I
ExceoUons
- Duct systems*registered with HERS provider as prrev usly sealed arre exempftrorr C 20 Duct Leakage Tegl'pg reeqqu eme�gts
Heating -only systems and Air Handler Furnace changes do not requireiverificaUon of Air Flow MCH-23gr RefFlieFant Cxharge MC. 25 �
Existing duct
systems'constructed; insulated or sealed with asliestoare exemp from MCHDuLe ge Testiquiremts
t -
. ,. 'lt::...A r._�ar1 •:.� �:. .e`xul. .. -. .. .. -.,.Y.MS.�. .. �. ..e .v... ...�.. _ ._,..,
.
xqi 'f �• s� n - .• vi+!'SLWi-".� ,.cVft ?73% '
E. Entirely New or Complete Replacement Duct4 stem, with or ithoutrEqulpment Chan eout (Se
li _ a
This.section does riot'apply to this project.
F. Entirely New or Complete Replace
ment:Space Conditioning System (Section 150.2(b)1C)
This•section does not apply to this project.
Registration Number: 217-A020039695A-000-000-0000000-0000
CA.Building Energy Efficiency Standards -2016 Residential Compliance
2(0)1Dnaoanc1 150:2(b)1E,: F)
e
Registration Date/Time: 2017-02-06 09:55:43 HERS Provider: CaICERTS
Report Version: 2016.1.005 Report Generated: 2017-02-06 09:55:46
Schema Version: rev 10/16
CERTIFICATE OF COMPLIANCE CF1R-ALT-02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT -HVAC) (Page 3 of 3)
I
.Documentation Author's Declaration Statement
i
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature: `
Robinson, Kevin
Company:
Signatire'Dater
J`ANTHONY PLUMBING HEATING &rAIR CONDITIONING
2017-02-0609:55:43
I
Address:
CEA/ HERS Certification'Identification (if applicable):
72216 NORTH SHORE ST -#101
City/State/Zip:
Phone: j
THOUSAND' PALMS CA 922,76.
.76Q 343-2121
Responsible Person's'Declarat'ion statement I ,.
I certify the following under penalty of perjury, under the"`laws of the State of California:'
i
1 •;The viformation provided on,this Certifiitate`�of Cort p6ance isxrue and correct.
ti u 3 -4
2 I am eligible under Division 3 ofahe Busrnessand. ProfessionsCode to accept respons16ility for the building design orsystem design identified on thisCertificate of Compliance (responsible designer).
3. : That the energy features and ''p rformance specifications mate als o ponents;`and-manufactured, devices,for._the.building'de'sign - Wsystem'design identified on this Certificate of Com liance.conform to the
P
requirements of Title 24 Part.1 and PSW6-f the California bode of:;p3e ulations- _ }
gs-
4. y�r2 "'.$...t R' D
.3,y
,
4. The building designfeatures ocsystem deslgnfieatures.identified o this Cemfic'ateorf Comp lance a�"e a ,nsistent wit ,the mformatio ; rovided;on tithe a licab ecom liance documents 'workshe t
calculations; plans and specifications sub"mitted�to.the e�t1f rcemen�♦t�a�g�ency forapprzoJ wl thisbuildi;ng per It ap licationl .`Y 1
.; 5. I will ensure`that a'registered copy of this;CectificQ�mphance shall�e�madefavailable with+�tfwte;buildipg¢pefmit(s)ussued fo�t_h�building, fable
and made ay to'tbe�enforcement a enc for all a licable
inspections. I understand that a registered copy of thi e i icate of Compl�Jances's requ r d to beeinduded, tFi'the•documentatioi the b llder provides t.q,re budding owner at occupancy.
. .. �� :»� � �� c�-�� " � �� •: a. wt .a ami. rr�.. �.
Res onsible Desi nerName:''
P g _>
Responsible Designer Signature:
.
Robinson; Kevin' '
„s
K171
Company:
Date Signed:
J ANTHONY PLUMBING HEATING & AIR CONDITIONING
2017-02-06 09:55:43
Address:
license: ;
72216 NbRTH SHORE ST #101.
y
777794
City/State/Zip:
Phone:
THOUSAND PALMS CA 92276
760=343-2121
Digitally signed by CaICERTS. This digital signature is provided in order to secure the content of this registered document and in noway implies Registration Provider
responsibility for the accuracy of the information.
Registration Number: 217-A020039695A-000-000-0000000-0000 Registration Date/Time: 2017-02-06 09:55:43 HERS Provider: CaICERTS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-02-06 09:55:46
Schema. Version: rev 10/16