0203-358 (SFD)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 �y jryq p�
17 4a88 � 1 69,6
VDate , 4t �� st Signature of Contractor's M _�a,f,.•t
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.
Q) I have and will maintain workers' compensation insurance, as required by
Section 3.700 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 ` Policy No.001��RACdE INS,
(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 f -= those provisions.'.I /
Date:' ` = � % Applicant—
Warning:
F . j �)
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ��1 i'-%/�-� Date'
BUILDING PERMIT PERMIT#
DATE VALUATIONLOT 0t�f" * '39 TRACT
f -}'2 ; , " . 0 2 24197.5
JOB SITE
ADDRESS `79-778 RAND01MR �UI
APN
- 6(X_072-=
OWNER
CONTRACTOR / DESIGNER / EN INEER
i.;1�"!,`V"IA LMOW-611t.CX')>! AU141TIRS
CE1+3MfiY'C_RPWFL1CC`MMUMf ES,
153530, OXY IF P.K.M. WE #200
1533 50.6 O.Mm' 'M A3'3`%". feloo .
8,AV kVC�t.'.IqARD190 CA .92408
ISAN MRAM3140 CA 92408
(90'�9)-.481.60 r ul 2120
USE OF PERMIT
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:C �,�I.4La}. �i�t�iL. f7�JXY,117.1t7^A R.Z
COOSTRUCTION FEE 1(11.000-41$,*)0 $594.5
4
ILA CHECK YOM 101-0,605439-318 $499.25
MFICl1.M1=1 Ful 101-000.4.21-000 $5155
EL'i•/:e'" =11.r1i;w F1121i1 to) _0101 o11:10-00 e' �1a9.*1
M11 INO ME. 101.000419.000 3110..0
MOM. MC3'i`IOP M, 4 REED 101-000-241--000 $8.0
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CITYOFLAQUI14TA
FINANCEDEPT, tk
fA ♦
RECE.IPT
DATE
Ai 1-o 2.
BY
• /�!
DATE FINALED
.o v
INSPECTOR
19
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
` BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ i -
Underground Ducts
Forms & Footings
—29
Ducts
Slab Grade
4 _1A9__
Return Air
Steel
X - -2-
Combustion Air
Roof Deck
--Z6 -Z
Exhaust Fans
O.K. to Wrap
_ S� - Z
F.A.U.
Framing
Compressor
Insulation
c 3-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
7 - 7i
Drywall - Int. Lath
- ry
Final
Final i
BLOCKWALL P ROVALS
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
- Z
Heater Final
Water Piping
Plumbing Top Out
_
_
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
` r 5 • o Z Sj
Encapsulation
Gas Piping
Gas Test
6 -((• d 2 5 7
Appliances
Final
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) p • -OZ 7
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Codo, Title 24, State of California, in the building |noabad at:
. �
/
` 7S'778Randolph Court, Lot 2, LaQuinta. California �
CEILINGS: �
TYPE: BLOW MANUFACTURER: CERTA|NTEED THICKNESS: R'38 �
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENERAL CONTRACTOR:
TITLE:
PA�RAC
�
N SCHM|O BUILDING PRODUCTS, AMASCO COMPANY L|CENSE#632073 �
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
`
tp�711
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
I- I vt-JI
Pr sect Title
J �.i " F� k j rJ hl / F�iC I- Wk L 11-4 C. LA k� L I Id TA
Project Address
Joe- 1,7,0 61 wso 772- 5 15,3
Builder Contact Telephone
HER
Firm: 261-c- T lCl.iE25�( �R�/IBES
Street Address: j c�. F—�-pX �p22 1
Copies to: Builder, HERS Provider
5
DatT---
6.F-: J T Li
Builder ame
FLA,d s
Man Number
GM 2.o tJ P
Sample Group Number
_ l.o T # 2 79.778 R.4ju col -PH
Sample House Number
HERS Provider: �, I� d� . E• IZ, �.
City/State/Zip: GIIH�,P,�c,t` /tg7a
HERS RATER COMPLIPA CE STATEMENT
The house was: El Tested C 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
ith the dia;mostic 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.
❑ iVIll-NItMUM 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 now 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) ❑ ❑
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
❑
❑
Yes is a pass
Pass
Fail
❑ 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 flow has been verified. If no TXV,
verified fan now matches design from CF- I R.
Measured Fan Flow =
Yes for both I and 2 is a Pass
Pass
Fail
Compliance Forms August 2001
A-16
r
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: 79-778 RANDOLPH COURT
1
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0203-358
Occupancy.Group.: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: CENTURY CROWELL COMM.
Building Official
Address: 1535 S. "D" STREET #200
City: SAN BERNARDINO, CA 92408
By: STEVE TRAXEL
Date: 12-06-2002
POST IN A CONSPICUOUS PLACE !