0401-146 (BLCK)1` ` LICENSED CONTRACTOR DECLARATION f
i hereby affirm under penalty of perjury that I am licensed under provisions of
PERMIT#
BUILDING PERMIT
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.' Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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DATE VALUATION LOT 0401-146 TRACT
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Professionals Code, and my License is in full force and effect.
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License # Lic. Class Exp. Date
JOB SITE
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OWNER
CONTRACTOR /DESIGNER / EN (NEER
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Date ✓� Signature of Contractor
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OWNER -BUILDER DECLARATION
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I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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License Law for the following reason:
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( ) I, as owner of the property, or my employees with wages as their sole,
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compensation, will do the work, and the structure is not intended or offered for
USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
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contractors to construct the project (Sec. 7044, Business & Professionals
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Code).
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() I am exempt under Section B&P.C. for this reason
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Date Signature of Owner
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WORKER'S COMPENSATION DECLARATION
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I hereby affirm under penalty of perjury one of the following declarations:
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() 1 have and will maintain a certificate of consent to self -insure for workers'
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compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
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I have and will maintain workers' compensation insurance, as required by
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Section 3700 of the Labor Code, for the performance of the work for which this
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permit is issued. My workers' compensation insurance carrier & policy no. are:
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Carrier a%`1'A`fla 4�UND Policy No. 16OV301-.2001
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(This. section need not be completed if the permit valuation is for $100.00 or less).
CONS9 RUCTION FEE ) 03.00 7.4'1 B-000
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( ) 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
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subject to the workers' compensation provisions of Section 3700 of the Labor
visions.
Code!' --shall forthwith comply with thos ro
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Warning: Failure to secure Workers' Compensation coverage is unlawful and
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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
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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
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-$14.00
whose request and for whose benefit work is performed under or pursuant to
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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
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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.
RECEIPT
DATER
DA ALE
INSPECT
Signature (Owner/Agent)r�%! Date '¢s
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INSPECTION RECORD
F 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 POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs j Electric Bond
Footings o QY Main Drain
Bond Beam L c Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final ly 12_zLd_.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
COMMENTS:
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)
WT- X16
Dowrt : -
$ ENERGY
�► -- CADEC
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ervices —
PO. Box 621
Rancho Mirage, CA 92270
Email: DESNRG (MAOL.COM
Ph/Fax (760) 564-2044
Cell: (7601250-1852
CERTIFICATE OF -FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7)
PASADERA PH -4
Project Title
P.G.A. WEST LA QUINTA
Protect Address
STEVE VAN LUE II 760-801-3981
Builder Contact Telephone
GRANT RICH 760-260-20841
HE ater (� yJ Telephone
i��.t� #CCNGY207439 03-19-04
Certifying Signature Date
Firm: DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
03-12-04
Date
ASHBROOK COMMUNITIES
Builder Name
PLAN 1 2 UNITS
Plan Number
GROUP 3
Sample Group Number
LOT 76
Sample Lot Number
HERS Provider: CHEERS
CF -4R
City/State/Zip: RANCHO MIRAGE, CA. 92270
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.
❑ The installer has provided a copy of CF -6R (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, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
I
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
4 Measured
Duct Pressurization Test Results (CFM aQ 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
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑ ❑
provided for inspection
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