0203-360 (SFD)i
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
1114188 B
Date'' `Signature of Contractor ! 1. ® r„i�')
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.
0 1 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. M orker.�' coif�1 7�pensation insurance carri r & yolicy no. are:.
Carrier r �'U �ttj'T.:' !,. Policy No. VC -5406840
(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 provisions..,,)
Date:1 f- ' : Applicant—
Warning:
pplicant 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.
ry1
Signature (Owner/Agent) Date'
BUILDING PERMIT PERMIT# 4
DATE VALUATION $1,1.8, 921 -LOT TRACT Z4197-5
JOB SITE 79-4/Xi RA"'bf.LPH CO
APN 6SV V f�Gr 1 h7
ADDRESS
OWNER
CONTRACTOR I DESIGNER / EN (NEER
CEM Y CROWELL CJa tahl i
CDT1 xis > �Z�t1WE I COMWINIUM
1535 No, IV MIM -110 07100
1.,535 so. ODO ar.9m, Ulu 47,00
SAV i',RRNARDWO CA 92468
SAW ^ER�7,F�Cta:il TO CA,ryry��92�,4j0
:r
��9 9 �j /�
(NR)n1-6007 CKAY. 2120
I
USE OF PERMIT
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pp004, S83 bp. ipavSmY}vpyliiWpcFt!. .iwi azPi..Y,:.1alminx,
REDUCTIOW FOR 'MU1,TIP1Z MSUMICE OF SAPVr, PY.!' . t'YPr,
TRAM CONOTRUCTIC44 SF
POiiCP1fMI10 11.06 se
t" ARAtyWARPO'W 4!1,71? BF
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118e0592D
MipUr JUvGpFIZ
Gum1tUC` oi; rn 201000.418.000 $7061 (0
Pi.ALN CHECK Fft $14117
A WIFIAXIC L RE
XLWITRIGAL VEX 101-000-4-20-000
a
PLUMBING i 101 -000.419-NO W&C
0
ST R4)V. G ?AOTIM FOS • RMID 101-000-29-1--000
DEIVE1,0PER Slef;PA6T J' $1,90?.(
0
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U.M. 111"t 3 -PAID :t7F. 1
114 S0100
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in
7 �PERIMFEEN DW.', NOW
CiryoFLAQUIWA
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NAN EDEPT
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
/
` 4.
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
= d-7— I
Underground Ducts :{ .
Forms & Footings
I -Z-
Ducts
Slab Grade
1
Retum Air
Steel
ZF .-
Combustion Air f
Roof Deck
_ 2 LExhaust
Fans : {
O.K. to Wrap
—
F.A.U. [
Framing
Compressor f
Insulation
_
Vents f
Fireplace P.L.
Grills [
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines f
Party Wall Firewall
} {
Exterior Lath
- C9
Drywall - Int. Lath
�l
Final [
Final ari
BLOCKWALL A PROVALS
POOLS.- SPAS
Steel [
Set Backs
Electric Bond if
Footings
Main Drain [
Bond Beam
Approval to Cover I
Equipment Location
Underground Electric : [
Underground Plbg. Test [
Final
Gas Piping f
PLUMBING APPROVALS
Gas Test ;[
Electric Final ; f
Waste Lines _/✓
-Z_
Heater Final f i
Water Piping
Plumbing Top Out
_
Plumbing Final I f
Equipment Enclosure ;!
Shower Pans -
O.K. for Finish Plaster [
Sewer Lateral
Pool Cover +[
Sewer Connection
2-- 57
Encapsulation [
Gas Piping
I
Gas Test
�p -. !/ vZ
Appliances
[
Final i
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring Q�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
i�
,.
1
i
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:
79-753 RANDOLPH COURT
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.:
0203-360.
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
�
INSULATION CERTIFICATE
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`
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:
79-753 Randolph Court, Lot 4, La Quinta, California
CEILINGS:
TYPE: BLOW MANUFACTURER:CERTA|NTEEO THICKNESS: R-38
WALLS: A
TTS MANUFACTURER: CERTAINTEED THICKNESS: R-13
GENERAL CONTRACTOR: CENTU o�"
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
B TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/26/2002
'
11 CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
I - I /,?I,J-i I
Prosect Title
Ftr -t=K c.)til/ F D W 1►JC L IW A-
ProJect Address
Joe Roelosoo (2,1 772-3 150
Builder ContactTelephone
i<�� C7Gvl ��G �oel-4—
HERS'Vater
Telephone
_ #t�NRKG/3z�L II/u
Cenirying Signaturebat(
Firn�:(�ESE2T �►.IE�.�`( �-ERS/I�E�
Street Address: j!c7.I �X 61,21
Copies to: Builder, HERS Provider
I 5 Te r� I' I 4-/o z
Dat—re ,
-r Li 0E �
Builder ame
FLAtJ 5�
Ian N� umber
GI 20 LJ F, 2.,
Sample Group Number
La :T 4:1-- 4 '74,z53 ZWTaLP9
Sample House Number
HERS Provider:
City/State/Zip: K! KlP_hlo e�A.°) 77o
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested Approved as part of sample testing, but was not rested
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 -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)
Measured
values
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)
❑
❑
Pass
Fail
❑ THERNIOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
❑
❑
Yes is a pass
Pass
Fail
❑ tNUNIMUM 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 -IR and
design on plan.
-' QSYes ❑ No TXV is installed or Fan flow 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
Compliance Forms August 2001
A-16