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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Vate +�wi - Signature of Cont a tort J /9 , t`
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&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.
'y I have and will maintain workers' compensation insurance, as required by
Seci'ion 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 EE`WTH INSURANCE Policy No. ZM,2062506
(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 orthwith comply with t ,ose•6rovisioris.
Date: --�"� Applicant $ � „ - wA
Warning: Failure to secure Workers' Com ensation 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 prope y fo'r, inspection purposes.
Signature (Owner/Agent)%? V Date.',1
r 1
BUILDING PERMIT PERMIT#
f
DATE VALUATION LOT 02(M-142 TRACT "
!
y
�j« 4312 -0c $775100 9 lei
JOB SITE
ADDRESS «M751 D AMEVID IUM
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
1I"[ RPIN Coyflcllrplucllow Co,
'L'URPIN CONDI Vit% CIMON CO.
7E-120 CALLEF ` ADO#206
78.120 GAUXMADO #206
(760)777-7611 CI3;` i 31151
USE OF PERMIT
(ANU L. $T,3Ia9.,T."11140 .
SLt1-%R :e411 XTA)... PERMITTO #0005.205.61.L F, SIN tA'et,C k1q °i7+'AU,
k Z^TAJ3dN0 WAL6) E'ER WON MR!) STANDARD,
6 Ff. WALI, 31,09 Lit
ESI' :A'L':1 C O,'f'Fr OF C'ONS117-113 UfLON
711 t0)
COITS'f!'t'C1CT1014 Pk% ' 101.000-418�000
3
C1Ty0FLA01jaKj. °�
F61!,!u1r��- „3,
SUB -16' AL CON MMU =011 AWD P lid C^I i�t';X
$21.M
1X3,05 PR9-�PAID TW
3 MOO
'TOTAL L"ET;id IT FENS DWE NOW
$21.00
RECEIPT
DATE/
BY -�
D FINW-ED,.
INSP R
V
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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
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
Appliances
Final
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)
COMMENTS:
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTINCF-4R
//JG �
Project Title Dater
Project Address
Builder Namb
Builder Contact Tele hone Plan Number
� Cc yrwa�Vl 2I I b--7aL 3
HERS Rater _ Tele hon Sample Group Number
ertifying Signaturey� ate Sample House Number
Firm: ��� r755� HERS Provider:
Street Address: 7V City/State/Zip: Gr Q12)nr Gbg -�53
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: JZ 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.
2 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.
❑ 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 /� 3
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) =, �5;y 2, 7b
Check Box for Pass or Fail (Pass=6% or less)
❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
Z -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
1 nCF-1
R and design on plan.
NI
/{f,//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
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
Project Title
Project Address
keii1
Builder Contact Telephone
IL_//.,.L� .�.. `LIQ -C-77
HERS Rater
S ftifying Signature j/ Date
Firm:
Street Address: 7`�F,7
Copies to: Builder, HERS Provider
Builder dame
Plan Number
Sample Group Number
Sample House Number
HERS Provider:
CF -4R
City/State/Zip: 2-1a z54; 9;�-,r3
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
co m I 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
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.
INIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) -96 values
Test Leakage Flow in CFM
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 l�
Leakage Percentage (100 x Test Leakage/Fan Flow) _, S '7
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
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
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING CF -4R
Project Title
Project ddress
Zl
Builder Contact Telephone
HERS Rater _ / Telephone
Q7 ftifying Signature Date
Firm: -(J-Z �- A-!�'
Street Address: Z7i
Copies to: Builder, HERS Provider
d
Date
Builder Namdd
Plan Number
Sample Group Number
Sample House Number
HERS Provider: /���7 SS�'�I
City/State/Zip: !//�A 4,Mift Gam/
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.
❑ 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.
❑ 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
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
LgJ THERMOSTATIC EXPANSION VALVE (-TXV) or Commission approved equivalent
eyes ❑ 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
CERTIFICATE OF FIELD
CATION AND DIAGNOSTIC TESTING
Project Title Date '
751
Project Address , Builder Narnfi
Builcon/t-�ct i eiepnone
)NL 1i1v�D o2%% �70�J
HERS Rater _ Telephone
CO(ifying Signature / Bate
Firm:
Street Address:
Copies to: Builder, HERS Provider
Plan Number
Sample Group Number
CF -4R
Sample House Number
HERS Provider: '3G �-- &G� U Z
City/State/Zip: 441/Pi 2AT G� %
HERS RATER COMPLIANCE STATEMENT
The house was: wrTested ❑ 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
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.
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) 'h� -g values
Test Leakage Flow in CFM
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
q
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fail (Pass=6% or less)
❑
❑
Pass
Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
9rYes ❑ 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
♦'
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
I
Project Title' 11 J Dates �' 6m5-�,
Proiect Address Builder Name
BuilOr Cont tTelephone Plan Number
C. d-t'ISSU� 2l;' -57,? -3
Sample Group Number
C0&ying Signature / Ddte Sample House Number
Firm: �C-� ���UG HERS Provider: `l iii �- 00SSUZ
Street Address: �%�vb�y /3�"/2Gf��Y'C City/State/Zip: G4 y'IJ)k&
Copies to: Builder, HERS Provider
CF -4R
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.
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.
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
I
Duct Pressurization Test Results (CFM @ 25 Pa) iJ 1, �� values
L7/
Test Leakage Flow in CFM
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) JET—
❑
Pass
Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
IYes ❑ 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