0310-203 (SFD)LICENSED CONTRACTOR DECLARATION
I helinby 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
,r
Date ,1. 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.
(?il 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 ?E1,,9"I(YNA:I. UIC.�iN F Policy No. 7165K:
(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�_;j:,`, 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-meritioned� property for inspection purposes.
{, .t. I S
ISgnaturef (Owner/Agent)`! 4 ... , a R te^ Date
BUILDING PERMIT PERMIT#
E;3;.Q-103
3f��
DATE VALUATION rrXl.� LOT Sit TRACTJOB
SITE
ADDRESS 0)- IM PR-Li
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck —
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation Erg
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL PROVALS
steel
POOLS - SPAS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) '
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
i
APR=02-2004 FRI 11:51 AM WESTPAC AIR COND
Imsta latiaou CertifWatc Residential
Site Address
60-347 Prickly (Pear Lane
1. lillll,l)ER INFORMATION
,Shoa l Ionics -T rilogy -T.aQuirlla
bU t11 Ti ilop,y Pkwy
I.0 Quint;i, CA 92253-7612
FAX NO, 909 739 9509
CF -611
PERMIT #
SI.1131)IVISION: Trilogy,, La Quihta
CITY: TA Quints
COUN'T'Y: Riverside
P. 14/24
INSTALLING CONTRACTOR; WEST YAC AIR CONDITIONING
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2. PRO,)ECT INFORMAT(ON
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j M'ST_ IMITTt)N iNK71_n[tPIPING R-
T I? VALUE
Rl xihlc Flexible Ductwork
i bi Atlie and `Will:brie a R -Value
Itelwcrtn floors of 4.2 or Better
i
1, the uudeisigoe+l, verify that the equipment listed in the category above ply signature is the actual cquipntent
in lalled hid Ili -at (hc equipment niects or exceeds (lie requirements of (lie Appliance Iii'iiciency Standard~. In
i addition, ihave verified that the equipment is equivalent to or more eft iciest than the equipment specified on the
Cerlilicatc of Compliance submitted to dcmonstrale compliance with the Lsnergy EfficieneyStandards for
residenlial iiuildill"s,
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3. REATING IWORMATION
I1l;ATING MANUF'ACT JIF,ATING UNIT AC1'UAI, EFF. HEATING EQUiP 1113-ATING
TiQU11'. MAiai MODT?T. # AFUL+ CAPACITY LUAU
humace Lennox SOUI-IG4/SX-100 80% 100000
80%
d. COOLING iNFORMATION
CO OLINC; MANUFACT COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
EQUIP.: MAKE MODEL HSF,]-',R CAPACITY LUAU
A/(' 13ACC-000 12
The hilimirig design, heat loss raid design heat gaut rate' have been detcmtined using a method specified in Section
i moo oflhe lineiF;y I?fficieney Standards; and are two of the criteria used for equipment sizing and selection.
6:1111h;'I; MOSTATIC EXPANSION VALVE (I -XV).
Therniastalic [expansion Valve (or Comniisiou approved equivalent) is installed and access is provided for -inspection.
Yes No ..� N/A
o. sui mrri,io) -By
Signtitore Installing 11VAC CnniraCtor
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f 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 at
14
60-347 PRICKLY PEAR LANE LOT 57, LA QUINTA CA
1 j
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CEILINGS:
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
R
WALLS:
TYPE: BLOW MANUFACTURER: Certainteed THICKNESS: R-13
GENERAL CONTRACTOR: SHEA HOMES LICENSE #
z BY: TITLE: ,
9, p'
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517 1
R
BY:
2el TITLE: ACCOUNT REPRESENTIVE DATE: , I C
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