0307-374 (SFD)LICENSED CONTRACTOR DECLARATION
U)
�I he Eby affirm under penalty of perjury that I am licensed under provisions of
F– Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
CV) License # Lic. Class Exp. Date
CY LO
r` W 7fvd335 B 03631/2(
oZ r- Date �f yt /��' Signature of Contractor
(O 2" }
J U 0 ' OWNER -BUILDER DECLARATION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
(n 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). L.
co() I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O1� -
Q 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 'STAFF, MAID Policy No. . 16091,401-012
(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 sh I� I forthwith comply with those provisions.
Date: f1 rti,r+>+'i+ Applicant
to ! , fits
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 i
work is not commenced within 180 days from date of issuance of suc
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 i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �.r -E Date` % p ICS
BUILDING PERMIT PERMIT#
7-374
DATE VALUATION LOT TRACT
$214,107.30 68 29147-2
JOB SITE
ADDRESS g7•-=)3LAC K f TAUfO
APN
7$11-. -;024
OWNER
CONTRACTOR / DESIGNER / EN INFER
CPIV (K%L''FWai"
ASI�BTtf7OXDr,'J1~:i,01JIShEff, Ci3M.T04Y
5140 AVENIDA M10N AS
5140 AVM)A.�.,.�b"CWAS
CArd,:M' AD CA. 92008
C_ PJXBtD CA 92005
(760).804-686S 3376
USE OF PERMIT
04CILE F 1viiT. LiV � LSi`Ti3
SF D - TAT 6$, P1,AR 1ATF.. PERMIT !'O'&S NOT INCLUDE BLOCK
WAT.,T. % P0014 3P•►1 OR DRTV1~WA'i'' APPROACH. 75% REDUCTION TO PLAN
C:iVECK TO MUL'F'1PLN F:;SUA.I4CF OF SAME PLA1,1 TYPE
CUSTOM CONSTRUCTION %501.00 S.F.
FORCWPATIO 5511.06 EF
0ARAG WCARPORT 605,00 OF
r
RSrMAM C09r CI? C0WGTP-UC1'I(' N
214,107.30
CONSTRUCTION FU 101.0100-418.000 $1,042.00
PLAN CHECK FEE 101-000-431-318 $213.1"38
MF:CH.AN1CA6 F XB 101-000.4.2.1.000 5111,150
ELLECTWC.AL IVE9 101-000-420-000 $133.14
PLCimnio niz 10'1-r70041.9-000 $157,75
S'FI2:fDNO A+1O110N FEF RE -310 1101-000441-000 . $21.41
ORAD)NO FF& 101.000.423.000 $15."
.
F�L'VT:X.OP�•.R.FYs�?FiACT1rQ� �2,Qh9.fs€►
ART tN PUBLIC PLACM - RES11 27.0.000.44: X000
9U" B-V..)TAL CON3SMIJ'i:'.tTOX -AND PLAII CIRMCK. • .
$4,174.45
PRE -PAID, M�3
$0.00
�'QT'AL J�� 19' 9 JD1V+' NOW
&1,174A ,55
NOVLFS3
N 14 2003 .
CITY OF LA QUINTt4 /
FINANCE DEPT ✓✓✓
RECEIPT
DATE "
BY
DATE FI LED
INSPE T R
"INSPECTION RECORD
OPERATION
^�
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade J
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing a
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
,Qrvwall - Int. Lath
COMMENTS:
Final Z7 4Y
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)
J
Final
Final el &I,
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
COMMENTS:
Final Z7 4Y
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)
J
�
T -*66
Down
EDIERGY
1B11 "A Gas e
P0. Box 621
Rancho Mirage, CA 92270
Email: VESNRG @!AOL.COM
C A D E C
Ph/Fax(760)564-2044
Cell: (7601250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7)
PASADERA PH -5 DATE TESTED 6-14-04
Project Title Date
P.G.A. WEST LA QUINTA ASHBROOK COMMUNITIES
Project Address
STEVE VAN LUE II
Builder Contact
RICHARD KROWN
HERS Rater
#CCNRK613292
Certifying Signature
Firm: DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
Builder Name
760-801-3981 PLAN 1 2 UNITS
Telephone Plan Number
760-260-1852 GROUP 4
Telephone Sample Group Number
J[ 7 12004 LOT 68
Date 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
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
T6st 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
provided for inspection