0203-363 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C•Fapter 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]4188 ``'10/31M
Date F;,'•'%" `? 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 OOL.DIr.I4ZACiX,1AS> Policy No. l C..�44 6>7 -flit
(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 provision.,
Date: f Applicant ' �`� t/ .�1=�,,
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) ' !� (="� �^ - Date, % r'
BUILDING -PERMIT PERMIT#
° 63
DATE VALUATION LOT TRACT
4403107M 7
JOB SITE
APN
ADDRESS 179: -74 RANDOLPH 0L URT
�+�^�•I �v �bl�
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CE7c3'�€ t RY CROW M". CG1VA3u3. N_ r
Mri`lli' r C"RIat ELL C°C1 .L tXRrIUM
1535 so, s, TrAi?G"!,
aM;�'iAi:AIMINO CA 92408
Mlq MWAMODRD CA, 924 08
� C1 �3SlaCiOA? C;3L.0 21-1.0
USE OF PERMIT
MINE EAM, Ly IMMING
sm � X1,-1PLAN >C.PIRMIY.17S 140T114MUL)FBLOCK VIALL.S,
P001,S AOR1MA AfS44yC19r &NKWXQ,79
REDUCTION IiOKMULTIPLE ISfWANCF, OF SI:: E PLAN TYPE
TRACT C'ONVAUC1TION i,'3,sS.691 9,F'
'01.i'.CHIP:ATIO 919,00 SF
C10,ACtWCA:R ORT 41ISM OF
COST OF C:?4"r%�S'�.i�13'G'•LI4..7�N
1 �kt?-��^�JM
spy �, /�y [� y;. gA��19T
.'IER,LY.U.d� l.W�.^: A9�JA8S7.7.V.IH07.ii.b .
C:aH. 0TT3'tiCTION FSE 101-000.418-0047
PLA14 CI4KK I MI, 101-000-439-318 $136, 61
MWIWICJA.3.na 101-000.421.000 $60,00
111, Y,C TAICAL r1 K.F 104 •00a_4 20-000 2117.24
P1.UMB190 FFR :1 Q1.000.4.1 MOO M".00
STR.P.. NO MOTION .IPPE - RESID 101-000-241:•000 $10:31
s; R AMINO PCZ '101.000-4233.000 $'.14A
?�1►�1.0.!•�E,fi.I,ft�I".e3.S..=T i+'EII: $Z,yCiJ�.00
.q
..t
SUR -TOTAL C;0_1#S't"RIM1701.1AND 1.>LW Ca`�''�.C:aC
$3,034.07
_
I I'M&MVEM DUE If ow
MAY 11 2002
CITYOFLAQUIRaTA
FINANCEDEPT.
V*
RECEIPT
DATE +
BY
DATE FINAL D
INSPECTOR
INSPECTION RECORD
+I
OPERATION • I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs rj — —
Forms & Footings —Z
Slab Grade —Z! --
Steel .5-7-9-2
Roof Deck 2— —p
0. K. to Wrap 33—AR 11_51P
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
DATE
PLUMBING
APPROVALS
Waste Lines
I I
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
r
Sewer Connection
D 7
Gas Piping
!
Gas Test
Z 57
Appliances
;
Grills
{
Fans & Controls
Condensate Lines
I
Final
Utility Notice (Gas)
ii
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Final
Rough Wiring
- _��5
Low Voltage Wiring
-
Fixtures
Electric Bond
Main Service
Main Drain
Sub Panels
Approval to Cover
Exterior Receptacles
Equipment Location
G.F.I.
Underground Electric
Smoke Detectors
Underground Plbg. Test
Temp. Use of Power
Gas Piping
{
Gas Test
E
Electric Final
Final
`
Utility Notice (Perm)
D • 10v
OPERATION
DATE
IkINSPECTOR
MECHANICAL APPROVALS
Underground Ducts
I I
Ducts
Return Air IZ
Combustion Air
r
Exhaust Fans
i
F.A.U.
!
Compressor
{
Vents
;
Grills
{
Fans & Controls
Condensate Lines
I
ii
;i
Final
;!
POOLS - SPAS
f
Steel
�(
Electric Bond
I
Main Drain
Approval to Cover
I
Equipment Location
Underground Electric
it
Underground Plbg. Test
{
Gas Piping
{
Gas Test
E
Electric Final
{
Heater Final
{
Plumbing Final
i {
Equipment Enclosure
[
O.K. for Finish Plaster
o{
Pool Cover
d;
Encapsulation
I
Final
COMMENTS:
I
II .
I
i
f
li
i�
i
i
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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:
79-795 Randolph Court, Lot 7, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CONTRACTOR: .CENTURY CROWELL COMMUNITIES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT
DATE: 11/26/2002
t CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
1, ...^
ect Title
J fr Fes- e K 5 ,c) d.Z F 2= Q WA U I N G LA L2 L.J I IJ'TA
Project Address
Joe 80610 so d
Builder Contact _ , Telephone
HERS Rate
'S( 4,204
' Telephone
X � I Uu
Ccfhiying Signature bate
Firni: FD ES _dF-Z- ( R\/Ie-E5
Street Address: Eo.
Copies to: Builder, HERS Provider
L
--� 5 Z ��- ° I 4;L02
Date
C -r-: dTLJd n 5
Builder ame 3 G
FLA,id
Plan Number
GI 20 LJ
Sample Group Number
Lo -0:'--7 lQoZ4S ecWwLPN
Sample House Number
HERS Provider:
City/S'tate/Zip: IA -L -Ho (`ltfdAG A-°i2>7Q
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested Approved as part of sample resting, but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply
� ith 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)
Duct Pressurization Test Results (CFM @ 25 Pa)
Test Leakage Flow in CFM
If fan now is calculated as 400cfm/ton 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) =
Check Box for Pass or Fail (Pass=6% or less)
❑ THERMOSTATIC EXPANSION VALVE
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
'provided for inspection
Measured
values
Yes is a pass
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
❑ Yes ❑ No ACCA Manual D Design requirements have been met (rater has
verified that actual installation matches values in CF -I R and
design on plan.
-' Yes ❑ No
TXV is.installed or Fan now has been verified. If no TXV,
verified fan now matches design from CF - IR.
Measured Fan Flow =
Yes for both I and 2 is a Pass
❑ ❑
Pass Fail
❑ ❑
Pass Fail
❑ ❑
Pass Fail
�P
Compliance Forms August 2001 A-16
Certificate of Occupancy
City -of La Quinta.
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that,.at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 79-795 RANDOLPH COURT
Use Classification: SINGLE FAMILY DWELLING L.. Bldg. Permit No.: 0203:363
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY CROWELL COMM. Address: 1535 S. "D" STREET #200
City: SAN BERNARDINO, . CA 92408
By: STEVE TRAXEL
d Date: 12-06-2002
Building Official
POST IN A CONSPICUOUS PLACE