0212-183 (BLCK)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 – r" Signature of Contractor err' sf~
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). 11-11
( ) I, as owner of the property, am exclusively contracting with licefted
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason r,
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.
( ) I have and will maintain workers' compensation insurance, as required by
Section 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:
Cartier STA'TR CC1M PkTid"v1'ATI Policy No. 49.00 tt:E' IT 001"
(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 tAose pr visions.
yDate:r 1 -`L, < Applicant-
Warning:
pplicant 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;-hisx
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, indemnity
& 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 cessailon 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-mentloned propert for inspection purposes.
r .;,.
;,Signature (Owner/r.Qgerifi.— � � �/.W/Date �F _ -'�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 021121-18111TRACT
JOB SITE
ADDRESS :�Jr�.>Gti�:AR�t��lAPN
cl
OWNER CONTRACTOR / DESIGNER / EN (NEER
$11-310 AVE TATE&MAYDA,0 41 -? 80 BERWrAGY, DR
TA QT.11.tw' I, CA P225:3 %SERINMA DUMES CA 92201
USE OF PERMIT
ra"t" OUZB'C:dllDIP2O
141.,E 4' OARD=1 BLOCK WJU L (0=0 ;3'Ya x.b��l� FOR PROPA.NZ TANK
A F7. WA&L
FSTH"' kID COST OF C'63MMUC1170R,
ITRAW 117' ' ' ,'s"U1QtlWlft,RV
C:ONS1131OC1 ION 1''1;17, � t1'i At4C3d"r ' -UOiT I S,t�
SM4C%M C:O2�'►r�iZUsw3.°T0941R?P3W CT',FA
JU I DEC 3 0 2002 0
CITY OF LA QUINTA
FINANCE DEPT -
RECEIPT IDBY
/J
/✓�. ,
F900111' F MKIS 1)IJE NOW
3
$15.00
$0100
$1 `4.
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs /: 03 ��!/
Footings !
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
_
Final `���
Gas Piping
PLUMBING APPROVALS
Gas rest
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
JAN -08-2003
CERTIF
10:06 PM
CATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING
Proiect Title
.65 .1 fir% s /l'y-� �il�Vl�lyrXgS G
Prosect Aaaress
Bji sv Cunt ct
HERS Rater _ ___e
4)
ilder Name
Telephone Plan Number
I9phone
01
�Xmfying Signature / 4Oate
Street Address:
"Ples to Builder. HERS Provider
Sample Group Number
P.01
CF -4R
Sample House Number
HERS Provider:�_,�4UC
City/State/21p: / o L4
HERS RATER COMWANCE 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
com®ly 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 leeks at duct connections.
6
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pe) values
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated here /yl�
value
If fan flow Is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fall (Pass=6% or less)
❑
Pass Fail
t THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
9(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
I . ❑ Yes ❑ No RCCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1 R and design on plan.
2 O 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
0 ❑
Yes for both 1 and 2 is a Pass
Pass rat.
6