0310-212 (SFD)LICENSED CONTRACTOR DECLARATION
I. t hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W , Professionals Code, and my License is in full force and effect.
O co License # Lic. Class Exp. Date
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o Z t` Date Signature of Contra.tor
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OWNER -BUILDER DECLARATION
W W r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z_ ( ) 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
N Date Signature of Owner
ON
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d Q WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q C)(r) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier IYh`ii }0..i:, ai ?i:.:,1 �� Policy No. 7165V�3
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Q (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
3 Cortle I shall forthwith comply with thos` provisiq s.,.�.•,..,,,, ,,�
Date: ����, ''� 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 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.
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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 herebyjauthorize representatives of this City to enter upon
the -above-mentioned pro erty,for inspection purposes.
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Sig,ature (Oyvnh r/.Agentf� Date `
PERMIT p
BUILDING PERMIT
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DATE VALUATION LOT ,.p TRACTJOB
SITE
ADDRESS �d"1e �: �3i i -�?:
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OWNER
CONTRACTOR / DESIGNEREN (NEER
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USE OF PERMIT
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EPT. /
RECEIPT
DATE /
BY
DATE FI ALE✓IN1179
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INSPECTION RECORD
$ OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade '
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
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 3 a
BLOCKWAI 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 APPROVAL
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
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Gas Test
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Appliances
Final
Final L5 Zz�,L,4,
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
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Utility Notice (Perm)
COMMENTS:
APR -02-2004 FRI 11,52 AM WESTPAC AIR COND FAX NO. 909 739 9509 P. 19/24
Ilkstallat ion Certificate: Residential CF -W
Site AdiltSs PE'RMI'T
L #
0-237 prickty Tear T,aue
I,1JUILDER INFORMATION SU96IViSTON:'C'r 109Y (a) I.a Quiltta
Shea IT��Illcs-'l'rilo;ty - i.ouinta CTTY: La Quillta
60;111 "I riloJ;,y Pkwy COUNTY.- Rivetsido
T.a Qnirwi, CA 92253-7642
iNSTALLING CON'i-RAMR: WEST PAC AiR CONDiT[UNINC,
2• PROJECTINFORMATION
RMATION
T)IC'1'1tJ�fiTJ'l'lC)i�T,- l)UCl' QR P[1'1NCi R-
F1e.xiblo Ductwolk hlexible Duetwark
in Attic and Wil11 iave a R -Value
lxchveen 11loom of •1.2 or Better
1, tele »nci�'rsit;n� �1, verify that the equipment listed in the category above my ,ignahire is the actual equipment
justallcd and thal.the equipinetnt meds or exceed~ the rcquiruments of the Appliance Efficiency Standards. In
addition,1have vurilied that the equipment is equivalent 10 or more efficient than the equipment specified on the
C;ertilicge of C,u1rlpliance submitted to dentunstrate compliance with the Energy Efficiency Standards for
residential buiktings,
A. IJ rr ATJNG INI ORMATIUN
11F;,kTIN('i MANU[�AC.`T IIEATINOY UNIT ACTUAL F, ifEATING 'QUIP ![}?A11NCi
liQUIP. MAKE MODFL # AFUC CAPACITY
Y i,oAn
G40LAI-488-090X , 80% 88000
( 1Ir1131L' Ee17110`i 80 %
4. COMING INFORMATION
COMING MANUFACT COMPRESSOR ACTUAL FF COO -I ACI-QYJIP C'OO' INQ
MA1;G GT
MnU•/f
A/C Lccuu�x 13AC:C-048 12
The exulting design heat.loss an<1 design hear gain rate llave been detenuined using a method specified in Scetion
150(11) o[the Llmergy TUfi6elIC Standards, and ON two Of the criteria used for equipment sizing and selection.
6: L'TjI,,KMODS'I'ATT(. l�.XVANSIO)N VALVE (TXV)r
ThcrmastMic Lxpausion Valve (or Commision approved equivalent) is installed and access is provirlc for inspection.
Yes No L...� NIA
6. filllifi IT 1'ED BY
DATE:
Sizyualurc fnslallmg IIVAC COtlifactOr
�Hrli/U/%/i//.fY.:dL'i!//dd/U/!//6/!//d/d/!//U/d/!J.'d/d/U/U/!//d/u..//d/d/B/O/d/d/d/d/d/d/d/d/d/d/d/d/O/.//U/d/d/!//Uid/U/d/UiU/diU!//u.7/d/d/d/di!/,'.fY/U/E'/d/d.0%liU/U/diI/.%/F//!✓/U�%U/U/!/.r!/.F//Yi!%/y
INSULATION CERTIFICATE 3 r
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This is to certify that insulation has been installed in conformance with the current energy
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regulation, California Administrative Code, Title 24, State of California; in the building at
60-237 PRICKLY PEAR LANE LOT 62 LA QUINTA CA
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CEILINGS:,
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS:. R-38
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WALLS.
TYPE: BLOW MANUFACTURER: Certainteed THICKNESS: R-13
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GENERAL CONTRACTOR: SHEA HOMES LICENSE #
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BY: TITLE:
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PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517
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BY: TITLE: ACCOUNT REPRESENTIVE DATE: G
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