0306-471 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
I— ChaP;er 9 (commencing with Section 7000) of Division 3 of the Business and
-W Professionals -Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
LLJ
o Z r ; Date Signature of Contractor'
CDO��'
rl- i.- o OWNER -BUILDER DECLARATION
_J (-)(0
W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
Lce)ID () I am exempt under Section B&RC. for this reason
N Date Signature of Owner
O�
CL z WORKER'S COMPENSATION DECLARATION
o 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO FZ p () l have and will maintain a certificate of consent to self -insure for workers'.
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m QC) 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
0� LOH permit is issued. My workers' compensation insurance carrier &policy no. are:
? z Carrier STAV' FAVYiD Policy No. 4tR
0
J (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
Codel`shall,fo, hwith comply with those`(�rovisions.
.�D'ate: �° ;Applicant ✓ !��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null'and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to.cancellation:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for in pection purposes.
f Signature (Owner/Agent) ' ` r6 %" ""� Date
r
PERMIT #
BUILDING PERMIT������t�.
DATE VALUATION VIM,' '�fytl3 LOT '�" > .r- TRACT X9147 -'t
1 y r
JOB SITE::IADDRESS f 'F� !dP Iai41�1 "v Jl.C�ItT3
APN 'It 11�QD
OWNER
CONTRACTOR/DESIGNER/EN (NEER
(MV (AC)3;YI WNT
5 i/j.C1ANMWDA92.-R,f'+�3V$
MIA 3376
USE OF PERMIT
FOMYGY IF F
t .FU:! ;� Piz" 2.G'9.. ,rJ.4 "M .ti jiptL-t Mod N^t1,V.7.tt:l1'7-,5eff, ,315..io-,3p .
FF Z DtI F. `'0 ML11.",i I P I I E 131:I.A'N G,1' L'101104r1 E i'FA14 TIP, P E
f1 a o
:� ; 7Ct:tH ruCi?� ir:iUi �zC7h? 261.9.00 ISFL
2003
PORIC:PIi1"ATIC� 515-00SIPJUL
2 5
I
CITY OF LA QUIIHTA
FINANCE DEPT
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�s:��,l�. �7.rI•tR,
fit', F
TW,xt FEE,
101 _000-41 "00 S11066.30
PLAN 0: N:",K "2 101•-000-43=X338 0.7aX
ML+C.:3:fsNKIAL Me& 1-01µ7':.0.42.L0 ) $12 .
`+� L ,C,1"v'liC./t L FEZ -Ov," 420-000. 313511,41
S`fI?0140 )!,I'oTION F29 Y pl' 'SIV s 01 _01G.-0_241 -000 $:13.12
IRADM FEE -,-005)-42 a«000
ART ,(M i'UBIX 1}I,,AX1' .- RUIL 276-000-44r-000
$4,20.39
itEr
(al?.CCt
Tutu. NOW
s44,2,0'?z.9
RECEIPT
DATE
BY
DAT ALED
INSPEC
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
15
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Duds
Forms & Footings
Duds
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
12,1
DrAmll -1 . Lath
Final
Final
POOLS - SPAS
BLOCKWALL
A PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
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
41
Encapsulation
Gas Piping
Gas Test _ p
1
.0 If ALF
Appliances
Final
-COMMENTS:
Final -7 (�—
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures o
Main Service
Sub Panels
Exterior Receptacles
G.F.I. 11101
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
1'c r -K � 5
59- 770
&A -CK D «MCN D
Gesan -
ENERGY �'� CA0EC
Sces —
Po. Box 621
Rancho Mirage, CA 92270
Email: QESNRG @AOL.COM
Ph/Fax (760) 564-2044
Cell: (760) 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -413
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
760-250-20841
HER ater
UTelephone
#CCNGY207439
03-19-04
Certifying Signature
Date
Firm: DESERT ENERGY SERVICES
Street Address: P -O. BOX 621
03-12-04
Date
ASHBROOK COMMUNITIES
Builder Name
PLAN 2 2 UNITS
Plan Number
GROUP 3
Sample Group Number
LOT 75
Sample Lot Number
HERS Provider: CHEERS
City/State/Zip: RANCHO MIRAGE, CA. 92270
Copies to: Builder, HERS Provider
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
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 400cfmlton 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 11 ❑
provided for inspection