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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalt\/ 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
"7�i%Sig �i ' )!"s ►1�:•
Date "'f Signature'tof 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 Xi3.1VJP Q 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,prov sionw" -
Date, .2' ; 'S ;: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 inspection purposes.
Signature (Owner/Agept)�"4f %�-'/�= Date—)
'ERMIT #
BUILDING PERMIT '
0MA-140
DATE • ^ "' `1 VALUATION LOT TRACT
ADDRESSJOB SITE 77-2M5 >i`.( iN" MIM&A
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
RMI)y B IS
i.e",GACV' k1C)2rlM
;,el.oga
LA Cj1JM-m CA 9125.3
11A QUA- ITA C, A. .9 Z 3
(760)MA-7532,0 (10111p; 021061%
USE OF PERMIT
POOL ANDIOR SPA
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PLAN CHECK FEE 101-00439-318 118 Elftl i;t%' .
COWS'TRUC TION P:t't. 101-000.4 13-dbs'1, 0 $1162 "Ti
ME'CHAINICAL FEE,- FOOL 10 1 -.000421, -0400 S304
E12JXTRICA.i. FX'IF Pf i�.)t, o141)00'420" 1'r -i VA V. 1i
1').;itIVIDNG FEE . P�+>'.:�','' . iia S9f1(f��i,)•U(2ts $2"l.!i�?
APR 24 20031`
CITY OF LA QUINTA
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RECEIPT
DATE
BY
E FINAL D r'
INSPECT
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 Footings Ducts
-Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
,.O.K. to Wrap F.A.U.
Pmminn Cmmnrnccnr
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
- d
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
p?
Underground Electric
Underground. Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Mater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
I Encapsulation
7_/ , rJ?
COMMENTS:
Final ..
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low.Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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CASA SEDONA
PLAN
LENCH DESIGN GROUP
P.O. BOX 450
IA QUINTA, CA 92253
POOL
PAOYF: (760) 56!-1966 FAX: (760) 56$-7.27
POOL PLAN
PLAN
ARCHITECTURE & CONSTRUCTION
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CASA SEDONA PLAN LENCH DESIGN GROUP
P.O. BOX 450
LA QUINTA, CA 92253
POOL PHONE: (760) SM -1866 FAX: (760) 5"2Q7
POOL PLAN PLAN ARCHITECTURE & CONSTRUCTION
JUL-14-2003 06:43 AM P.04
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING CF -411
Project Title / f j Date -
ProjV odress Bulld Name•
Buiider Cont ct Telephone Plan Number
HERS RaterTe eph ne Sample Group Number
d
C ing Signature ate Sample House Number
irm:HERS Provider.
Sweet Adarass" erZ C je., City/State/Zip: Zo 2cuag
Copies to: , Builder, HERS Provider
HER RATER COMPLIANCE STATEMENT
The house was, Tested ❑ Approved as part of sample testing, but was rot tested
As thg HERSjater providing diagnostic testing and field verifioation, I. certify that the houses Iden ified on this forrn
co y with the diagnostic tested compliance requirements as checked on this form,
In iribution system is fully*ducted (i,e,, does not use building cavities as plenums or platfor n rett_rns .n lieu
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ducts)
Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are use d In c,)mbination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections,
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPWANCH 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/►on x number of tons enter
calculated value here
If fan now'Is measured enter measured value here _
Leakage Percentage (100 x Test Leakage/Fan Flow) = Y�
Check Box for Pass or Fall (Pass,6% or less)
❑
Pals Fail
I THERMOSTATIC EXPANSION VALVE_ (TXV) or Commission approved e� quivalent
`Yes C3No Thermostatic Expansion Valve (or Commission approved
❑
equivalent) is installed and Access Is provided for Inspection
Ate_
Yes Is a pass
Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN 6bMPLIANCE CREDIT
1 Q Yes 0 No ACOA Manuel D Design requlrements have been met
(rater has verified that actual installation matches values, In
CF -1 R and design on plan.
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2. 0 Yes 0 No TXV Is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF•1R,
Measured Fan Flow =�
' Yes for both 'I and 2 is a Pass
Pass Fail