9521 (RER)Building
Address 43-750 San Ped_o
Mailing
Address P. 0. Box 921
City Zip
La Qufnta 92253• .
Contractor
-Hoilii o' n Construdtio
Address .
16727 -Republican qday
City lZip
• ys.I•
P.O. BOX 1504 i N o . 9521
%ftwV9..-78-105 CALLE ESTADO
nj�LA QUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST: OCC: GRP.
A.P. Number
Tel.
Legal Description
Project Description =
Remodel existing house,-,`
-State Lic. City
& Classif. 1. `B 558552 - Lic. #
• Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION .
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing withSection
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following I
reason: (Sec.. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of theBusinessand Professions Code, or that. he is exempt therefrom, and the basis
for the alleged.. exemption. Any.; violation-of'Section 7031.5 by`any applicant Joi a permit:
subjects the applicant to a, civil penally of not more than five hundred dollars .($560): -
'' ❑ 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,.•Buisness and
. Pro/ess)ons. Code: The Contractor's License Law does not _apply to "an owner o! property who
builds or improves .thereon and who does,such:.work himself or through -.his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.) .
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to -an owner of property -who builds or improves thereon; and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) _
O 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm, that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec: 3800, Labor Code.)
Policy No Company '
❑ Copy is filed with the city. .❑ Certified copy is hereby furnished.
w ' CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.) -
I certify that in the performance of thg 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.
✓Date' . > J . ' .1 Owner .rf
NOTICE TO : APPLICANT: If, . after making this Certificate. of Exemption you ' should become
'subject to the Workers' Compensation provisions of the ' Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY -
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days. '
I certity that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-.
mentioned property for inspection purposes. `
Signature of applicant Date
Mailing Address
City, State, Zip
Sq. Ft. No. No. Dw.
Size 6'® Stories Units
New ❑ Add ❑ -Alter ❑ Repair ❑ Demolition'❑
PERMIT
Plan Chk. Dep;
Plan Chk:'Bal.
Const. `
Mech.
Electrical
IAMOUNT
25.00 ,.
15.00
15. 00
S.M.I.
.
Grading
Driveway Enc.
Infrastructure
TOTAL
mu, e"t x --fa- 1
REMARKS
W CASH I I W AL , A - L16 i 6;7
• ZONE: BY:
Minimum Setback Distances:
Front Setback from Center.Line '
Rear Setback from Rear Prop. Line '
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR '
Issued by! Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL SO. FT.
POR. SO. FT. ®
GAR. SO, FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SO. FT. ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used aE property tax valuation
ROUGH PLUMB.
FLOOR DRAIN
MECHANICAL FEES
HEATING (ROUGH)
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
DUCT WORK
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
GAS(ROUGH)66 G�' �[p
LAUNDRY TRAY
AIR HANDLING UNIT CFM
HEATING (FINAL)
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. FT. ® c
BATH TUB
BOND BEAM
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.;.U.
SO. FT. RESID ® 1% c
SEWAGE DISPOSAL
LUMBER GR.
SO.FT.GAR ® 3/4c
HOUSE SEWER
FRAMING �
FINAL INSP crl$
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.F. PLCK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE / PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING Z`
oUNDERGROUND
A.C. UNIT
COLL, AREA
SLAB GRADE
0
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS/
SEWER SEWER OR SEPTIC TANK
ROUGH WIRING.
DUCT WORK
ROCK STORAGE
FOUND. REIN
GAS(ROUGH)66 G�' �[p
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT.
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
plus x$
=$
LUMBER GR.
FINAL INSP. 1( etL L
FRAMING �
FINAL INSP crl$
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FI EWALL
HI l fq(cO
MESH
INSULATIONISOUNDd' (/2/q
FINISH GRADING
FINAL INSPECTION-
NSPECTION
CERT.
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
.
CERTIFICATE OF COMPLIANCE: RESIDENTIAL
-
Page
.1
� CF-1R
Project Title.........; LUCAS ADDITION
Date........
05i01/91
Project Address.....,.. 48750 San Pedro .
--------------�-------
°
' . La Quinta CA
_Documeptation Author... C. Randall-Christensen
Building
Permit # /
Company....`............ T-24 Energy Calcs Co. . .^
| P.
|
Telephone.........`...,.. (619> 360-0535
Pla�� Chec.
/ Date �
Compliance Mbthod....,, MICROPAS3 by Enercom", Inc.
.
' � Field Check/ Date' �
`
�.
Climate Zone........�. 15 � ' '
---�------------------
MICROPAS3 v3.01 File-BAXLPKGA Weather-CTZ15
Program-FORM CF-1R
|
� User#-MP1017 User-T-24 Energy Calls Co.
_______________-___-______________________________________________________
Run-DShdsR19.30
`
|
`
' ' GENERAL INFORMATION
`
'
'
----______________�
.Conditioned Floor Area..... 60 sf
�
-
Building Type.............. Single Family
Detached
Building Front Orientation, Front Facing
270 deg (W)
'
`Number of Dwe[ling Units... .02
' ''
- ' Number of Stories.......... 1
.' Floor Construction Type.... Slab On Grade
Infiltration Control....... Standard
^ GLAZING
'
'
Glazing ` Trea # of Interior' Exterior^'
^
Framing
.
Orientation . ~(sf) Panes Shading Shading
-------------------
.
' � Overhang
Type
------ r---- ---------- --"-----------
� ' � ,
Window Froht (W) 4 2 Shades None
-�---��-
. ��
None
-------- -
Metal .
THERMAL MASS
____________
.
Area Thickness 1Hard Surfaced/
'
Type ( sf ) �(in) Exposed Location/Comments
_________ ____�________
`------- �-_____. ______________________
` SlabOnGrade 495 3.5 ' Yes ent.kit.�vc
- .
' - ASSUMED HVAC SYSTEMS
'
____________________
Assumed Du�t �
Duc' '
t.
Assuhed System EftAciency Location:
R-val4e
G Is . 0.720 SE Attic '
R22.1
:Air:Conditioner ^ 8.90 SEER Attic
` .
���7.1 '
.
. .
, ^
ACTUAL HVAC SYSTEMS '
.
`
____________
. ` .
Actual Output Manufacturer/
and Model, #
Adtual System` Efficiency (Btuh)' (or-approved
equal) `
_____________________________
Heating '� ' ' Existing `
.
Coo ling` __________ Existing
Cooling Coil!
. ~ `
CEC Maximum Output for Gas Central Furnaces:'
. . .
.
-
' ''
.
~
Btuh ^
,
a
C=E=EB 1 I F' •1' C_" rE:: OF C;C-+i`'1r= L T ANC:'E: g RESIDENTIAL 5 n f ac..te. 2 QF-IR'
Project Title..!; . • .:: „ . LUCAS ADDITION Date .. . R .., ' i,5/if1./`_'1.
tl'1'LEa:-ir='F,'-q.°•v: .0Y File--BAXL_r='k::(.:,A tt!c_at_tne&-C'TZ15. Program-FORM L::E__..._IR
r U_ _ ' rk_ _ 7 r-2 4 Energy Ca r- n Co.- fuu--; Shds9
, 'i ,
SPR l: AI_ 1::: E_ATE_aRES /�TL�1°' A1=tk;ti
T.1• ig prCt..i'ect f_:C_nsist.s o .al 60 sq.,'f't: addition to at r'F?5ic1F'.1'3cC-.
• Tt ;c:1�.��il.i-3 7.F �.
for C=>C:;rci a.L 'Pajc:k.age A for additions ;Page' •1••-2 of
the Ener` y- Conser•v<at.ion ,Manual: ). � }
PAposed glazing,
:,.:'. (,:.. ., ' 1) • w1.ndi_iws s{
Glazing. r.'•{:::•mowe{.i' .
total, a - r
c� f, + V= 17.6 allowed glazing ,
Cop`/ of Prescripli•vr:•�Mck.�arly A •for`•C:'TZ1.c �t•L-.�t:�ii�t�ed.
f _
s
w L• 4 a A � •
'CERTIFICATE OF COMPLIANCE: RESIDENTIAL- - . P9oe 3 . CF -1R
=========.��==================�=======================�===================�=====
Project Title. . . . . . . . . . LUCAS ADDITION Ddte... . . . .. 05/01/91
MICROPASA v3.01 Fi le -BA ' LPKGA Weather-CTZ15 ProgramnFORM CA1R |
| ' User#-MP1017 User -T-24 Energy Calcs Co. ^Run-DShdsR19.30
��________________________�
'. . . . �
_� ________________________�__________________________
'^
^
COMPLIANCE STATEMENT
. . .
-------------------
,.This
------------------'This certificate of compliance lists.the building features and performance
specifications''needed to comply with Title 24, Chapter 2-53 and Title 20,
.Chapter 2, Subchapter'4, Article 1 of the California Administrative code. '
~ This ",certificatle has been signed by the individugl with overall design
responsibility and the building owner, Who shall retain a copy of it 'and
trahsmit th' certificate to any subsequent purchaser of the .^ uilding . When
this ' certificate of compliance is submitt-dfor a single building plan to
, be built in multiple orientations, all' building' conseivation ƒeatures
which vary Are,indicated in the Special Features/Remarks section.
. ^ . ' . .. .
DESIGNER � ' ' ./ OWNER ` ^
'
Name..., Richard Hollimon Name.... Richard Lucas'
Company. . ' Company. ^
Address. 81-875 Avenue 48 Address. 48750 San Pedro
' Indio CA La QuintoCA
�
Phone... (619) 347-9223 Phone... ~ ^'
� .
License..
. .
Signed ' . Signed
. - (date) � '' ' ' (date)
DOCUMENTATION AUTHOR `' ' ENFORCEMENT AGENCY
~
.
Name..j. C. Rand&ll-Christensen Name....
Company`. T=24 Energy Calcs Co.
Addrdss. '79-733 Count�y Club Dr. Agency.. '
'
` Bermuda Dunes, California :
Phone... (619) 360-0535 ' ` Phone...
'
. `
,^
Signed ~ I '
.
.
.
'
.
.^
�
� `.. .
.
�
. .
^
. .
. .
.
��
.
. ~
BEFORE
Removed portion of howse
r
1
t�
�--- Addison must salt comply
f Figure 7-1: Addition Must Still Comply If Remodeled Nouse
Has Less Floor Area Than Existing Nouse
F.
Addition Alone
Any addition --that is, the sum of all new
conditioned spaces and associated new exterior
walls, ceilings, and floors within the building --
may be shown to meet the energy budget as a
separate entity. This procedure does not
involve the existing structure, except to modify
the internal gains within the approved
computer performance method, and may be
performed using either a special prescriptive
package or the point system or any approved
computer performance method.
TSPECIAhPACKAGE A']
An addition may be shown to comply with the
Standards by meeting specific requirements of
Package A for the climate zone in which it is
located as stated in §2-5301(d)2C of the Standards.
The Package A features which apply to additions
include:
• Oiling, wall, slab perimeter and raised floor
insulation levels
- Glazing U -Value
- Shading
These Package A requirements are listed in Tables
1321 to 3216 in Section 3.4. In,this method, total
glazing area in the addition is limited to 16% of
7-2 Energy Conservation Manual
the added floor area. The net glazing alta takes
into account glazing "removed from the existing
building because of the addition." Therefore, the
maximum glazing area is 16% of the added floor
area plus the area of glass token out of existing
exterior walls and ceilings, tp make way for the
addition.
Package A for additions does not limit the amount
of glazing which may occur on any one
orientation, nor does it require any thermal mass.
Another feature of this special Package A for
additions is that electric resistance space and/or
water heating may be installed. All applicable
mandatory measures still apply.
POINT SYSTEM OR COMPUTER METHOD
ANALYSIS OF ADDITION ALONE .
Any addition may be analyzed alone using either
Elie point system or a computer method . The rules
for doing this are the same as for showing
compliance of any new building except that the
internal heat gain in Btu/day may have to be
entered `according to the following formula
(depending upon the computer method):
a Revised July 1990
J
ly
'fable 3 Z15 -Prescriptive Packages for Climate Zone is a
4
Package Package Package PacD g Package
Component , A BE
BUILDING ENVELOPE Ji
Insulation Minimums: 1
Ceiling R-30 R-38
R-30 R-38 .. R•38
Wt�� R-19' R-19 R-19 R-19 R-19
"�vya Wall }(R15.5) (R-4.5) (R-4.0) N/A N/A
Slab Floor Perimeiet
"Light Mass" l" [R-7.0) [R-6.0] [R-6.0] N/A N/A
10, - R-7 R-7 NR � N/A
Raised Flout R-19 R-19 R-19 N/A R•19,
GLAZING
Maxunum U•Value 0.65,E 0.65 0.65 0.65 • ; 0.65
Maxi/num Total Area NR 1 16% 16% 16% .16.%
Maximum Total Nonsouth Facing Area 9.6%... N/A N/A N/A' N/A
Minimum South Facing Area 6.496 NR NR � NR NR
SHADING COEFFICIENT._ I '
South Facing Glazing r 015 0.15 0.15 036 , . , 0.36
West Facing Glazing 0.15 0.15 0.15 0.36'''
0.36
East Facing Glazing 0.15 0.15 0.15 0.36 036
North Facing Glazing NR NR 0.36. 036
TEIFRM,g1;MASS3 REQ NR NR 25% 10%
INFILTRATION CONTROL f.
Continuous Barrier AIR REQ NR NR
Air -to -Air Heat Exchanger NR REQNR
NR NR NR
SPAC9,.HEATING SYSTEM
if Gas;. Seasonal Efficiency= ,71% 71% 71% 72% 72%.
If Heat Pumps►ACOP= [MIN MIN MIN 2.5 2S
SPACE COOLING SYSTEM
If Air•Conditioner6, SEER j MIIV MIN
DOMESTIC WATER HEATING TYPE
r 9'S 9.S
System must meet budget, :ANy ANy Solar w/ ANY ANY
see §2-5351(b) and 2-5351(f)(8) Any Backup
LEGH". NR a Not lt%uuv4 N/A a Not Applka* REQ a Reguirw
1. Tho vahao in paremthaea is the miniauR► R -value for the emtim wall useably euiudlu8 interior &W wkdor air tdm ifthis wan weight euc,ws
40 pouads pa squam foot. Tho valor in bmckc" is We rain imum R -value toe the entireasacrmbly it Wo heat capacity of Wo wan meso or ""C&the moult of multiplying the brackwed mmum iniR,valuo by 0.65. The iwulatioa must be integral with or insaned as the vutaide of Woe:tuior
mann• The inside sudaeo of the theroW mw$, iac111418 plaster or gypsum board in direct contract with this mmaty wan, shall be capoaod to the
room air. Ilia axtorior wall used to moot this R•vdw in pammthaa cannot also be used to meet Wo above tbortmal masa toquiromomt.
2. No aFocific nlaadwg must ba installed with double glaring to MOOT the 0.66 shading coefficient mquimrtWomt which ass m" liglt trapozy
3. To c+lculato the amount of thermal mann mquimd for Package A. use the method set forth in §2-53S 1(f)4. Padago D (far slab floor buildings)
a$ uim 25 ways. t o[ the" ground floor ams dimealy exposed to"eooditioaW space. Uucaarpcted (e.g.. lutoleum or tiled) grour►d floor aro$, such
uY .bathrooms. and oCoditiorhod utility 'COW or cloaca may all bo counted towards this tsquireuhemt. Package E (for raised
60" W"10 tequima a Wwmal mat era equal to 10 patent of this ground floor area. To qualify for thermal mann, the material wed mut
have' a padomharaoo equivalent to a two inch Wick mus decent with a voWmeuic heat capacity of 28 Butlf�•°F. •
Btu/►t-°F.. and a sudaca area ditoaly expwed to"rom air of the uired ► WF�aI caoductiviry of Q9S
m9 P�+Be of this ground floor.
4. The dm 17 requi
ICU than l7mmeny am auporsodcd by this ApplianceEfficiency Standards which mquite that all nanw
S.000 Btulhr manufacwmd on or after Jaauary 1.1988 have a rating of 72% SE or higher. Ayaa
totwt cow I" �°�a of
io+tallod io oogjunctiov with all $Paco hooting systental u ampt those noin section 23. V mitt bo
S. wHe as this ACOPmust mea the minimum 6.6 HSPF (Heating S "QW Pedormaace Factor) value Vecirod im tha AMU=" BKtcienq SWW&A6 u
(Adjusted Coafficisnt of pedorn ance) listed in the Tables
6 the listedABn tvr cooditiarca amd the coding cyclo of heat pampa MUMMA ted SEER (Swaomd Energy Efficiency Ruin) liatod jm ft Table
Y e4 which COW tba Appliance g(fhcienq SttWdatds also meet$ tb'b1W' Package mwtt requk for mdiCg....
3-26 Energy Conservation Manual Revised December 1987
MANDATORY MEASURES CHECKLIST: RESIDENTIAL MF -1R
NOTE: Lowrise residential buildings subject to the Standards must contain these measures regardless of the
compliance
approach used. Items marked with an asterisk(t) may be superseded by more stringent compliance requirements
listed on the Certificate of Compliance. When this checklist is incorporated into the permit documents, the
features noted shall be considered by all parties as binding minimum component performance
specifications for
the mandatory measures whether they are shown elsewhere in the documents or on this checklist only.
DESCRIPTION ;Desioner ;Enforcement;
BuilLa Envelope Measures
$Sec.2-5352(a): Minimum ceiling insulation R-19 weighted average.
Sec.2-5352(b): Loose fill insulation manufacturer's labeled R -Value.
;
1Sec.2-5352(c): Minimum wall insulation in framed walls R-11 weighted average (does not
apply to exterior mass walls).
'
Sec.2-5352(k): Slab edge insulation - water absorption rate no greater than 0.3%, water
vapor transmission rate no greater than 2.0 perm/inch.
,
e e
Sec.2-5311: Insulation specified or installed meets California Energy Commission (CEC)
quality standards. Indicate type and form.
Sec.2-5352(f): Vapor barriers mandatory in Climate Zones 14 and 16 only.
Sec.2-5317; Infiltration/Exfiltratior, Controls
e
'
, e
a. Doors and windows between conditioned and uncondition spaces designed to limit
,
'
, e
air leakage.
b. Doors and windows certified.
,
'
e ,
C. Doors and windows weatherstripped; all joints and penetrations caulked and sealed.
e
'
, e
Sec.2-5352(e): Special infiltration barrier installed to comply with Sec.2-5351 meets
,
'
e
"CEC quality standards.
,
`
e ,
Sec.2-5352(d); Installation of Fireplaces
1. Masonry and factory -built fireplaces have:
a. Tight fitting, closeable metal or glass door
,
e
b. Outside air intake with damper and control
`
c. Flue damper and control
e ,
2. No continuous burning gas pilots allowed.
'
HVAC and Plumbino System, Measures
Sec.2-5352(g) and 2-5303: Space conditioning equipment sizing: attach calculations.
;
; ;
Sec.2-5352(h) and 2-5315: Setback thermostat on all applicable heating systems.
$Sec.2-5316(a): Ducts constructed, installed and insulated per Chapter 10, 1976 UMC.
;
Sec.2-5316(b): Exhaust systems have damper controls.
Sec.2-5314(c); Gas-fired space heating equipment has intermittent ignition devices.
Sec.2-5314: HVAC equipment, water heaters, showerheads and faucets certified by the CEC.
r
,
Sec.2-5352(i); Water heater insulation blanket (R-12 or greater) for storage and backup tanks
for sonar w/h systems (first 5 feet of pipes closest to tank insulated (R-3 or greater))
Sec.2-5312(Exception I): Pipe insulation on steam and steam condensate return 6 recirc piping.
;
Sec.2-5318(d); Swimming Pool Heating System has:
I , a. On/off switch on heater.
b, Weatherproof instruction plate on heater:
c. Plumbed to allow for solar.
2. 75 percent thermal efficiency.
;
3. Pool_ cover.
e
e
' 4. Time clock.
,
5. Directional :rater inlet.
e
Lighting and ADoliance Measures
e e
,
Sec.25352(j): Lighting -25 lumens/watt or greater for general lighting in kitchens and bathrooms.;
Sec.2-5314(c); Gas fired appliances equipped with intermittent ignition devices.
:
Sec.2-5314(a); Refrigerators, refrigerator -freezers, freezers and fluorescent lamp
ballasts certified by the CEC. Indicate make and model number.
Form Revised July 1990