0403-106 (SFD)LICENSED CONTRACTOR DECLARATION"--,
hereby affirm under penalty of perjury that I am licensed under provisions of
1 Spier 9 (commencing, with Section 7000) of Division 3 of the Business and
rofessionals C66 and -my License is in full force and effect.
License # Lic. Class Exp. Date
ate. Jt ignature of Contraotor_
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�)/ 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 Policy No.
UNION Policy
618343
(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 sdias 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 shalh(ort6ith comply�Nrj thoseVrovisilons. "�•. ,
D te:� K-- ) (' A%plica %. S;W
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an'employ6r 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
applicationt
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 issuanceof 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 authorizes repgesentatives of this City to enter upon
the above-mentioned propertyfor)inspection purposes. `�
y Signature (Owner/Agent.) Date
:%ire:�:;t•, _ ... _ • ..
BUILDING PERMIT PERMIT#
DATE - VALUATION LOT 0403-1(% 1(% TRACT
JOB SITE APN
ADDRESS 60-719 (3RL>MWE CI12CY r., .lam -270-01.7
OWNER CONTRACTOR/DESIGNER/EN (NEER
SMA IA QUINTA Ur, 193HR& LA QCRN'CA LW
81260 A�1 M—TUT, 62 81260 A�)B 62
I.o-,QUTA TA., Cilli, 922S3 L.A. C?C3',�I�iTA. CA 922
USE OF PERMIT
UUIT 15, PLAN 4520B..PLR.IaU DOLES NOT INC:}.MDE POOL , SPA,
CWTOM 010NOTRUCTION 1.940.00 SF
PC?R(iI'1lPA,:IO
121.00 NP
C1.r1.Td.AQW.14111PO4T
489.60 BY .
r
197rKKATIRM COST Or' CONSFRUG
MIN
F.. t R 0 UMM i.RY
CONSTRUCT1014 ITE
101--W0418.000
E8631.50
PLAN d:HWX N'f+E
10li,-000-4339-318
M1.88
MECHANICAL FEE
101.000.421-000
$80.00
EUK'CTR:CAL f -WE
101-01("20-000
$11'1.16
P14MOTI301 FFR
101.0000-419.000
T146.75
STRO140 M0110I4 FEE m RMID
101-000-241-000
$1.5.36
OPI1:ialHO F , �,
01-000-423.00.0
WIN
10E'.EI.0.I''ER IMPACT MT)T
$7,405.00
10,630.10
:14'rC)'I' 4v:I1IaC. afi.014AND PI,.WI CURCK $4,339.65
MAR 2 4 2004 TAA PERAM r X wS :t}QI:.Nc N"; S4,nq,65
CITY OF LA (I1i;N-rA
FINANCE DEPT.
,RECEIPT DAiE_4� BY f DATEA f� INSPECJP�
4
INSPECTION RECORD
OPERATION
DATE 7
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturn
Air
Steel _
Combustion Air
Roof DeckExhaust
Fans
O.K. to Wrap _
F.A.U.
Framing d
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - IM. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROVALS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS '
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service 07
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
08/24/2004 10:22 7603401080 PARAGON SCHMID 206 PAGE 05/11
�•i•r-�ie�r.-r.trrr,+r, rnrr�r.r,....rr.»tai a•w: i . .. / �J`)
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
eegulation, California Administrative Code, Title 24, State of California, in the building at a
60-719 OROURKE CIRCLE LOT 1015, LA QUINTA CA
CEILINGS: '
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
WAL S:
TYPE: BLOW MANUFACTURER: Certainteed THICKNESS: R-13
y
GENERAL CONTRACTOR: SHEA HOMES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517
r
BY. TITLE: ACCOUNT REPRESENTIVE DATE: 'U
r
r
i
3
Yrs �ivn/uur�r.,iianviiv.�.riiirriiyiyri�irniri.r.,iiriiii�/�irririr. irirsiniinn•�.ni»•rnr•ri/iiiiirrii iiuirii..r�.riiirn�i:.:.,�riiri�i iiiii..iiiii:.r�iirii:rrr:.
=,R
Installation Certificate: Residential
Site Address
60-719 Orourke Circle
1. BUILDER INFORMATION
Shea Homes - Trilogy - LaQuinta
60311 Trilogy Pkwy
La Quinta, CA 92253-7642
CF -6R
PERMIT #
SUBDIVISION: Trilogy (a), La Quinta
CITY: La Quinta
COUNTY: Riverside
INSTALLING CONTRACTOR WEST PAC AIR CONDITIONING
2. PROJECT INFORMATION
DISTRIBUTION DUCT OR PIPING R -
TYPE VALUE
Flexible Ductwork ' Flexible Ductwork
in Attic and Will have a R -Value
Between Floors of 4.2 or Better
I, the undersigned, verify that the equipment listed in the category:above my signature is the actual equipment
installed and that the equipment meets or exceeds the requirements of the Appliance Efficiency Standards. In
addition, Ihave verified that the equipment is equivalent to or more efficient than the equipment specified on the
Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards for
residential .buildings. .
3. HEATING INFORMATION
HEATING MANUFACT HEATING UNIT ACTUAL EFF. HEATING EQUIP HEATING
EQUIP. MAKE MODEL # AFUE CAPACITY LOAD
Furnace Lennox G40UH48B-090X 80% 88000
80%
4. COOLING INFORMATION
COOLING MANUFACT COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
EQUIP. MAKE MODEL # SEER CAPACITY LOAD
A/C Lennox 13ACC-048 12
The building design heat loss and design heat gain rate have been determined using a method specified in Section
150(h) of the Energy Efficiency Standards, and are two of the criteria used for equipment sizing and selection.
&THERMOSTATIC EXPANSION VALVE (TXV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is provided for inspection.
Yes F-1 No 0 N/A ❑
6. SUBMITTED BY
�S2C- l�tt'ctClC ICS %� M DATE: — 2 6 —
Signature Installing HVAC Contractor
('FRTTFTCATF of FIF,T,n VFRIFICATION. AND DIAGNOSTIC TESTING
Project Title
0a -- 9/ 9 i4g
Project Address
/I'Lyy/L
Builder Cont t /
//h Cr4?,OMO.f ✓1
HERS„Rater
CF -4R
Date '
#Z,)/
Builder Name
Telephone Plan Number
-57.2 3
T,elep one Sample Group Number
� D p
rifying Signature Da ' Sample House Number
Firm:..TC. d'�SSOG%it{�D eS HERS Provider: �G/��f,-�S�oG/�%S
Street Address: :�/'�✓�TOY4 c.IYGL¢� City/State/Zip: G/N
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: Tested ❑ 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
coly with the diagnostic tested compliance requirements as checked on this form.
Distribution system is fully'ducted (i.e., does not use building cavities as plenums or platform returns in lieu
f 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)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM fj U
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated value here
LYS
If fan flow is measured enter measured value here/
Ll'
Leakage Percentage (100 x Test Leakage/Fan Flow) _. D
Check Box for Pass or Fail (Pass=6% or less)
❑
ass Fail
L9—THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
A"Yes ElNo Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
❑
Yes is a pass
Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. ❑ Yes ❑ No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1 R and design on plan.
M
2. ❑ Yes ❑ No TXV is installed. or Fan flow has been verified. If no TXV, J /
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
❑ ❑
Yes for both 1 and 2 is a Pass
Pass Fail