0203-361 (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
714188 B r) 10/3.14(.
- �� 't .Signature of Contractor y .- y I - A'"`'
Date
.. f r Z,,. .... wLi
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 Gt'rY.DI E,ACi�, Fi1�t, Policy No. X17,+`C ,544069-0)
(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, 1 shall forthwith comply with those provisions.
Date: a . 3 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 personrat
whose request and for whose benefit work is performed under or pursuant16
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) Y '-J, Date ? .f ! <• r .
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0203"" *1 TRACT
-- � • C.� 8103.,01060 5 241.37-:5
JOB SITE APN
ADDRESS -�1�L�% ✓ti"O•E.IW . 6044Y724=
OWNER CONTRACTOR / DESIGNER / EN (NEER
I
C WI'CTRY CRL*T.LL 00-m vtU T S CA N URY CROWET.L C✓ yC)MivliXNITIM
1535 so: mo g1'mn, BTX n00
SAN BER14'MWZA O CA 92408 SAN M1<i'A13Vt;I O CA 92408
(QtO p all 6007 CI:31 11 2120
USE OF PERMIT
kWCfl-11AML Y DWEL 1NO
S10 - L40T 1y3 AnT',"stw. P&PW1'T WES 14C1'P 1;tft 1.C1OF ,fi ;,t3t:1 *lrl l ;
�t�Ot� �t'f�, t���, t��t.1�Ti�`.�t"�►."Y.t�P�C,�C:irF, 5;��� 1�i.�'�6 C�1j?��: �
RPMUC` ION FOR f~i+IULTIP12, ISS'if.414CE Ota SA'l 3 P1,M4 TYPE
TRAO WNersTRUC` IO V 1M5,00 3F
FChI e .ATM t %.00 SP
GARACILYC:`•A11Pr. RT 413.00 SF
ERMW-1ED CObv"t'r' C1� C:oh-gar17 ;'rJON 1W110-010.60
ff Wer"M4'`
CONSTRUCTION I�S
MAN CHWX MAW $136.02
MECHANICAL FEY 101.000-421.00€ $0,40
ftZO i`Rtl AL, RrRE 101 -41011 -420 -WO $1 MA
PlIUMBENG FF,T. 1071x000-419.000 Se30100
S:1 RONC) MOTION FEE' o;X' ',430 101-000441.000 $110.31
d++f8.ADIN01 A 101 -WO -423.000 $20100
T)MEI0PYR 1MFAC'!';rRlr
D 0. M.Al. C~ °I AND k All- i MR -C Y, s3pmof
M+ Y 12002 151113 PRE -PAM For, $0.00
'A .1'6i��'1+�I��:fi'1+'1s31-0r5DWE'AOw @4° 1,034 l
Cl NANCED P�A
RECEIPT DATE •BY DATEFINAyYD INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs S
Underground Ducts
Forms & Footings --2
Ducts
Slab Grade
Return Air
Steel — — Z
Combustion Air
Roof Deck a
Exhaust Fans
0. K. to Wrap —
F.A.U.
Framing
Compressor
Insulation — S _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines ,$—
Gas Test
Electric Final
Heater Final
Water Piping _
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection T7
Encapsulation
Gas Piping
Gas Test v L S?
Appliances
Final
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) Q 'AWOZ- 37
COMMENTS:
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t _ * i�..,'Fl y�v' pi .v .urs• y y. ; ,, _
3q.rr
,. ,� . J � .:. � ' r d;, i i��ia ,orf < w.� }„a ��•� �€ � '.� d . � - '! .. , •.,
-'✓i%O/7/1/O/O//il/1/!/1/O/I'Y9/Y%I//lA!/O/1/1/O/A/O/1/1/O/!/J/O/1/1/I/1/1/J/1/O/1/O/I/.//1/O/IFI/1/i7//1/I/!/1�1/1/1/1/1/1/1/I/I/O/.P/J//1/diP/1/P/1/I///O/!/1/1/1/N/J/!/li1/1/1/1/!/1/A/1/2'ii
INSULATION CERTIFICATE
This is'to certify that insulation has-been Installed in conformance with the current energy
a `regulation, California Administrative Code; ,Title 24, State of California, in the building located at:
r
79-767 Randolph Court, Lot 5, La Quinta, California
'CEILINGS: ,
TYPE: BLOW. .MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-13
GENERAL CONTRACTOR CENT V Y CROWELL COMMUNITIES -LICENSE # % �L
BY:TITLE: '
a PA ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY -'LICENSE # 632072
r aY TITLE4ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
i
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
ject Title
Project Address I ' ' ' .
Joy 90e10S00 0))772- 3 150
Builder Contact / Telephone
�I�H#,RI) r, 7(o)564•4—
H R er 11Telephone
Cenit in ignature ate
�F 5 -`� 4-/o z
Dat—, -e --��
C`� J TLJ n �E5
Builder ame
FLtaid 3C -
Plan Number
GI fza LJ P
Sample Group Number
l.o T 41' S -191 -767 /PAN 1b l P K
e Sample House Number
Firm:f�ESE2T ���EIz��(Rx/I�E� HERS Provider: L°,►� .�. E, R, `_>.
Street Address:t c�.F�.Ox (oZ ( City/Sta(e/Zip: Gd e -Ho iKA fit= 'FA.°)177o
Copies to: Builder, HERS Provider
HERS RATER COMPLIAACE STATEMENT
The house was: El Tested CJ 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 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 (TXV)
❑ 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.
I 7�O Yes ❑ No
Compliance Forms
TXV 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 I and 2 is a Pass
.August 2001
❑ ❑
Pass Fail
❑ ❑
Pass Fail
❑ ❑
Pass Fail
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: 79-767 RANDOLPH COURT
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0203-361
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
Date: 12-06-2002
Building Official
POST IN A CONSPICUOUS PLACE