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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
690645 B WC A 6130/04
i
Date " ~422 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.
Sec') I have and will maintain workers' compensation insurance, as required by
tion 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 ST.&,rp l)?lt) Policy No.
(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 rovisions. r�
Date: 1 1�:1V ..• Applicant—
Warning:
I
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 inspection purposes.
Signature (Owner/Agent) � .i ` - f� +-i IQ�A*f Date ---
V
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' BUILDING PERMIT PERMIT#
DATE VALUATION LOTC�-.n1� TRACT
103 29856-1
JOB SITE
APN
ADDRESS ! _M C+AARK0 PRN{t.DO
i ,14M4:-5
OWNER
CONTRACTOR / DESIGNER / EN (NEER
, 6 DON 810
14.25 B.
CA 92255
Rffokyrx A7, $1034
(602)257-1656 ( L0 4990
USE OF PERMIT
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C'J. IXX FEW DUE TO MIJiMPIX ISSU,A NCE OF $AMR P1,AW '.I"PEP
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PORCH/PATIO 860100.113F
C�A1��I,CJ1�.dC`•.1%�k'CJYS.T ��.,�il h�
NETS 69ATED COST CIF CONIURUC". ION
710018$112.00
C; t)NS'YRUC!`RYN ME 101-000=416-000 $493140
PLAN CHECK WWF. t 0 -000-431>•r3 x S $206.162
fiosr,C.rl ANICAL FEE. 101.000.421-000 MOO
=0CITRICAL A'L/f 10141=420.000 $201.30
PLUNIDT< O FEE 101.000.419.000 MUD
Sl`IZs3N13ayl�y�Q�TIONFEEa« RUSID 1t.0'9j-(f�?{.y0-241-jQ�f�;0
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MM -TOTAL CON METTIM101bT AM PLAW CHEM,
w IN9 3 PRE�Plt�D M1
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CITY OF LA Q0.ifN A
FINANCE: DEPT.
RECEIPT
DATE BY ,•
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
r
APPROVALS'
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Jy
Ducts
Slab Grade
- -
Return Air
SteelCombustion
Air
Roof Deck
- ? -'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
- 3
Compressor
Insulation
Z5- -
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
-/ -
Final -rJ3
Final D
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-
Heater Final
Water Piping
Plumbing Top Out
_
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-
Encapsulation
Gas Piping
_
Gas Test
, Q3
Appliances
Final
Final—(!�5
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
COMMENTS:�,iT-��'�g//s
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building located at:
50-160 CAMINO PRIVADO, LOT 103, LA QUINTA, California
CEILINGS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-21
LICENSE # 40t
TITLE: SI �l�T�dut�t�
SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003
INSTALLATION CERTIFICATE
3 of
'�"ro4t_tM U l 1.4- ?X- t o
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� Site.Address � , DPermit Number
G
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
LEAKAGE
Test Results (CFM Q 25 PA)
Test Leakage (CFM)`� — _
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity
in Thousands of Btu/hr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction:5 0.06
{� For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
❑. Yes ❑ No 0 Pressure pan test or House pressurization test
❑ Yes . ❑ No ❑ Visual Inspection of Duct Connections
❑- THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Yes is a pass
❑ DUCT DESIGN
I - ❑ Yes ❑ No ACCA Manual D Design calculations have been
- _ completed, Duct Design is on the plans and duct installation
matches plans.
CF -6R
11
Pass Fail
❑ ❑
Pass Fail
❑ ❑
Pass Fail
2: ❑ Yes ❑ No M is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -I R
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2. is a Pass Pass Fail
❑ 1, the undersigned, verify that the move diagnostic test results and the work I performed associated with the test(s) is.in
conformance with the requirements for compliance credit. [The builder shall provide the HERS provider a copy of the CF -6R.
signed by the builder employees or sub -contractors certifying that diagnostic testing and. installation meet the requirements
for compliance credit.]
Tests Signa , Date 1 ' tall g ubcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
ZP-
INSTALLATION CERTIFICATE
3 of
Site.Address Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE
Pressurization Test Results (CFM Q 25 PA)
Test Leakage (CFM) Cep
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity
in Thousands of Btu/hr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction. = Test Leakage/(Measured or Calculated Fan Flow) a
Pass if leakage fraction 5 0.06
CF -6R
09 D
Pass Fail
fl For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
❑. Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections ❑ ❑
Pass Fail
❑- THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Yes is a pass
❑ DUCT DESIGN
❑ ❑
Pass Fail
1 ❑ Yes ❑ No ACCA Manual D Design calculations have been
completed, Duct Design is on the plans and duct installation
matches plans.
2: ❑ Yes ❑ No TxV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF- IF.
Measured Fan Flow
❑ ❑
Yes for both I and 2. is a Pass Pass Fail
❑ 1, the undersigned, verify that the above diagnostic test results and the work 1 performed associated with the test(s) is.in
conformance with the requirements for compliance credit. [The builder shall provide the HERS provider a copy of the CF -6R.
signed by the builder employees or sub -contractors certifying that diagnostic testing and. installation meet the requirements
for compliance credit.]
1
Tests Date 1 stall' g Subcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY T0: Building Department
HERS Provider (if applicable)
Building Owner at .O.ccupancy
• nw
Dt-
ENERGY � r"'A ° E
S='` -
P.O. Box 621
Rancho Mirage. CA 92270
Email: Wrown62370aal.com
.sa -/60 4�'O�
Ph/Fax (760) 564.20"
Cell: (760) SWOOM 2SD-1852
M2p, , "M -, � ,
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CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -411
/DA /ih-1"G 1,4 Pte.
Projec Title Da
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Z sMlU AkdwCk (7&Oj pZ% - 377 wilder Na a `3
Contact C Telephone tan Number
W 2 - GI "t.110 It:
/
:at Telephone Sample Group Number
�c�►�Rlc i329� I I o -� Lo-T-� 10 3 ,�o? uin�
ng Signature Date Sample House Number
Firm: PESEe f F..&My 6E12VI eE3
Street Address: �0 • Spm( (i2
Copies to: Builder. HERS Provider
HERS Provider.
City/State/Zip: 6 90—Ho%� IIt<AyEELLit .g227o
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested L_] 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 -611 (Installation Certificate.
❑ Distribution system is fully ducted (Le., 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 Q 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=60/6 or less) ❑ ❑
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑' ` �1❑
Yes is a pass Pass `Fail
Page 1 of 1
14712 SW SCHOLLS FERRY
# 328
BEAVERTON,OR 87007' .:
PHONE : 6035248268
FAX: 503213-6222
E-MAIL: mjnelsonpattbi.com
Qhs
John Hardwick 2-27-03
RJT Homes, LLC
79700 50" Ave
LaQuinta, CA 92253
RE: Structural Observation of: Lot 103 and Lot 104
John,
Sample observations were made of the above house to ascertain whether the intent of the
construction documents is being followed. Of the structural items that remain uncovered and
easily observable, there appears to be reasonable compliance with the general intent of the
construction documents with no unresolved deficiencies.
Please call with any questions.
Sincerely,
A/A
hart
Mike Nelson, PE