0401-141 (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
Profossionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Datep�
�tj0 �5J B 3/31/05
Signature of Contractor
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.
(�) 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:
Carrier STATrz- FUND Policy No. 1609301-2003
(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 those provisions.
Date: "1 t .fr+ ,f 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 insbection purposes.
S gnature (Owner/Agent) - Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
f
JOB SITE (�q .(�
ADDRESS w�� ?{.{I L:.iItAL� GJ1Vtll7l.9df
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OWNER "'
CONTRACTOR / DESIGNER / EN (NEER
CIRV f: f�''1•l.:i.1'WH19T
J l 40 AVENIDA.MSC.MAS .
514 0 AWNIDAAZNC.LI A-9
C:R.I.N'iAD CA 92008
CARURAD CA 92006
(16T)804.6868 CBLA, 3376
USE OsF.a♦�PERMIT
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Mi.A�Y.l.3LYw�L.! �I�.J4�.N.1I :I
104 L.F. 6- 23.LdDCK WAIA,, CIT A? %TA'I+i0A.P,0
��.FR;C#'ED Ct3h""�; Ole 4"ONIS`�:RU�C711t)�'�f
2,700.0 0
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PERA ..i,.tl. �X!R iUlYlbo�B. RY
fwONSTRU :TION FRE 7 til -000.418.000 S54,0D
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SUP,AX)TAL MASTRUC IONAVID PLAN CIPECK
$54.00
LESS PRD PPID 1=4 1
$0.00
TMAL PERMIT L1.;'.pT K. �'i1:D.ES W:.r.f NOW i
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RECEIPT
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BY
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BLAU DIRMOND
Dewrt e -
PO.
NERGYCA0EC
Semceg
Box 621
Rancho Mirage, CA 92270
Email: DESNRG (BAAOL.COM
Ph/Fax(760)564-2044
Cell: (760) 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PASADERA PH .4 03-12-04
Project Title
P.G.A. WEST LA QUINTA
Pro'ect Address
STEVE VAN LUE 11
Builder Contact
GRANT RICH
HERS Rater
#CCNGY207439
Firm: DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
760-801-3981
Date
ASHBROOK COMMUNITIES
Builder Name
PLAN 3 2 UNITS
Telephone Plan Number
760-250-20841 GROUP 3
Telephone Sample Group Number
03-19-04 LOT 71
Date Sample Lot Number
HERS Provider: CHEERS
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
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)
- ❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ ❑
Pass Fail
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection 11 ❑
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