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06057 (SFD)Building Address 53-56d Cortez 23r. 6 Fors. Scott Morgan Mailing Address >e City Zip Tel. La Quintan 1 92253 v VIUC sawn $E Dennis Rickenberg' - 77600 Velaaware P.O. BOX 1504 78-105 CALLE ESTADO• LA QUINTA, CALIFORNIA 92253 Palm UesexT 922+30, 345-7307 State Lic. City A Class". 453778-B LiC. # a311 Arch., Engr., Designer Address Tel. CityI Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I aHtrm 1fMA am ( under provisions of Chapter 9 (commencing with Section e70N0�0):-., ions 'viefnjn,3jof the Business rofessloj(�1� Code, end my liic?ennsets in' full force p!pd 1114A DATE OWNER -BUILDER DECLARATION +� 1 hereby afraln that I am exempt from the Contractor's License Law'for the following reason: /Sec. 7031.5,8hs6hess and Prolitissimrs Code: Any city or county which requires a Permit ODconstruct, ager. Irprove, dermotish, or repair any structure, prior to its Issuance also requires the appill carnI AN suChr Permit to We a signed statement that he is licensed Pursuant to the Provisions of the Contractor's. Licensetaw, Chapter 9 (commencing with Section '7000) of 131Wslon 3 of the auslness and Prelessions Code, or tint. he Is exempt therelrom, and the basis for the alleged exempam. Any violation of Section 7031.5 by 'any applicant for a Permit andfectss the to a civil Penalty of not more Man five hundred dollars ($500). 0'1, as owner of the property, or my employees with wages as their sole compensation, will do the wadi, and the structure is not intended or offered for sale. (Sec. 7044, Bulsness and Rofeseiorrs Coda:'The Contractors License Law does not apply to an owner of properly who bids or 6proves thereon and who does such work himself or through his own employees, provided Mal'sutlh foprovements are not Intended or offered for sale. If, however, the building or Lvprovnmenr Is sob rlthlri one year of txtrnpletiorh, the owner -bulkier will have the burden Of pfa4g Mat he rid mat ironic ar ingaove to tire purpose o/sale.) ❑ 1, as owner of the property, amexclusively contracting with licensed contractors to con- struct the-pnaieeL (Sec. 7044, Business and Pmfesslons 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 r9h 8%=8) licensed pursuant to the Contractor's License Lew.) ❑ 1 am exempt under Sae_ B. & P.C. for this reason Data owner WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consegt to 'self -insure, or a certificate of Workers Compensation Insurance, or a certiied.cMCreof. (Sec.; 3800, Labor Code.) Policy No Compaq /.•Jf ❑ Copy is filed with the city. ❑ Certified oe'py is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This sectlm meed not be ompibed If One Pemdt Is for one hundred dollars ($100) vafua0m or fess.) 1 certify that in the performance of the work for which this permit is Issued, I shall not Lernplsq�person In any manner so as to become,subject to the Workers' Compensation NOTICE TO APDL. CAW. tl alter mabv this CeAftate. of Exemption you should become andfect to the 1111mhanrs' CorrpensaUon provisions of the Labor Code, you must forthwith con;* wish such Provisions or Ods Pam* shad be deemed revoked. CONSTRUCTION LENDING AGENCY I lneraby affirm that there is a construction lending -agency for the performance of the work far wddch lois permit is issued. (Sec. 3097, Civil Code.) Lenders Nacre L_eniers Address This is a building permit when properlyfilled'out, signed and validated, and is subject to expiration It work Ursraunder is suspended for 180 days. 1 certify that 1 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. raenUarred prapety for hhspection purposes. Signature of applicant Date Mailing Add,ass city. state. rip Numbe No. 06057 TYPE CONST. OCC: GRP.• r 77/4-131,103-1 Legal Description Lot 3 Bik 195 Unit 19 Project Description S.Q.U. Ft. 1630 No. No: Dw. NewX1 Add ❑ Alter ❑ Repair ❑ -Demolition ❑ 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 7-5-i.9 Issued by: Date Permit Validated by: Validation: Estimated Valuation 37 s�$9.Q1Q PERMIT AMOUNT Plan Chk. Dep. Plan Ch_k. Bal. 5,00.©5 Const. 585.50 Mech. 51-2.50 Electrical 114.69 Plumbing 157.50 S.MT 6.16 Grading 20.00 . Driveway Eric. p,g� Infrastructure 1967.93 TOTAL REMARKS 3rc'ir: , Mi A --It Fr "e`ti ';i 9 tG r, 5 15-; - a i r� 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 7-5-i.9 Issued by: Date Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL SO. FT. a $ UNITS COLL AREA �uLAB GRADE -2C -4 ROUGH PLUMB. YARD SPKLR SYSTEM 2ND FL SO. FT. HEATING (ROUGH) STORAGE TANK FORMS MOBILEHOME SVC. BAR SINK POR. SO. FT. ® DUCT WORK ROCKSTORAGE GAR. SO. FT. ® POWER OUTLET ROOF DRAINS METER LOOP HEATING (FINAL) DRAINAGE PIPING CARP. I SO. FT. GAS (FINAL) WALL SO. FT. DRINKING FOUNTAIN. SO FT ® WATER HEATER URINAL ESTIMATED CONSTRUCTION VALUATION E FINAL INSP. WATER PIPING NOTE Not to be used as property tax valuation WATER SYSTEM FLOOR DRAIN MECHANICAL FEES GRADING cu. yd. = plus xS WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTOXDISH) APPLIANCE DRYER ROOFING GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED /i �• LAUNDRYTRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET- COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER, B.T,U. SO. FT, @ c BATH TUB SPARK ARRESTOR SO. FT. C c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 116 c SEWAGE DISPOSAL LATHING fe%Y/V SO.FT.GAR ® 114c HOUSE SEWER GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR GOND. SOLAR O�SETBACK-� C( GROUND PLUMBIN -�/� UNDERGROUND A.C. UNIT COLL AREA �uLAB GRADE -2C -4 ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTI ROUGH WIRING DUCT WORK ROCKSTORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. REINF. STEEL GAS (FINAL) 2,6EMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. = plus xS =_ LUMBER GR. 19 1 FINAL INSP. ` RAMING`O-, -f--7 FINAL INSP. ROOFING /i �• REMARKS: VENTILATION FIRE ZONE ROOFING: FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING fe%Y/V MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL ' INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL City I Zip I State Lic. If LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am ncertsed under tlrovlalons of.Chapter 9 (oommencing with Section et� ion 3 of the Business and Profeesiorm Code and my ifcense is in full force and SIGNATURE DATE OWNER43UUJM DECLARATION 1 her afttln that I am exempt from the.t.ordractoes License Law for the following reason (Sec. 7031,5,Busbress and Pn*sslats G\ds: Any city or county t which re9uies a permit to constru ager, btprov% 1 9 f or repair any Structure, prior Its issuance also piorlsbna rt lafor such - N to r; (Commestatement thatncing with seis ction 700%50 Mon 3 of the Business and'Proftssions wda ar Utet.he ra susept Therefrom, and the beats. for the aBeyed wxenpf L Any rbala0m of Section 7031.5 tty' any eppacent for PerMf sutOods rhe appdcantto a dve penally of not more than lite hundred dopers ($500). 0 1, as owner of the property, or my employees with wages as Meir sole compensation, will do =and and the structure is not Intended or 1V (a sale. (9ac. 11044, Buferteas arhd Profesaiona Cods: Time Coimrador>; Lfcarrse Lar does Tier aPptY to an owner of Property who IN or knProves therson and who does such rorty hinsef or though Ips own etgployees, provided Rrad sack brprosenwo are not Intended or offered for sale. N, however. the Widths or inprovenrent ld sold wMd one year of oonp& F, the owner4u0der wS hors the Wirdan ofproving that he did not build or irprove for the purpose of sole.) CI I, as owner of the property, am exctusivelyconfrecgng with Iicensetl contractors to xron struct the projecL (Sec. 7044. B�sess and Prcfe®slora Code: The Contractor's License Law does not apply to an owner of pt perty-who bu9ds or btprorea thereon, andwhocontracts for such pro)eds web a contractor(s) 6eatsed Pursuard to, The Canbactoes License Lew.) 0 1 am exempt.under See -----R & P.C. for this reason Date owner WORKEW COMPENSATION DECLARATION I thereby affirm that I have a certificate of consent to self rtsure, or a certificate of Worker s Compensation Insunv xk or a certified copy thereof. (Stec. 3800, Labor Code.) Policy No—company 0 Copy Is filed with the city. O Certified copy is hereby furnished. CERTIFICATE OF EUMPTION FROM WORKEW COMPENSATION INSURANCE (This, section need not be carxpleted 0 the Permit is for are hundred dollars ($100) vahadon or loss.) . I certify that in -the perfonmanoe of the work for which thispermit Is Issued, I shall not employ any pers�� in any manner so as to become subject to the Workers' Compensation Lavre of Calitonhia. Date_Owner NOTICE TO APPLlCANr: It, albw rhe" 9 fMe CsrL %xft of Exemption you should become atAW to the Moment, Cor p�Con provisions of the Labor Coda. you must forthwith convoyIrM arrcit prehilslorss d Odepenoi sAaff be dsomae revoked. CONSTRUCTION LENDING AGENCY I her attfm that there is a construction lending agency for the performanceof the work for which this permit is Issued. (Sec. 3097, [Svc Cads.) Lenders 'N Lenders Address_ This is abuilding permit when filled out, signed and validated, and is subject to expiration t work thereunder Is suspanided for 180 days. I certify that'l have read this application and state that the above information is correct. 1 agree to campy with all city and county ordinances and state laws relating to building xxmsbuctlon, and hereby aulhortae repro of this city to enter the above-- mentioned property for Inspection purposes. Signature.of applicant Date Mailing Addreas— City. state, tip FINANCE stimated Valuation PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL 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: ' cu 4 1QUA P.O. BOX 1504 APPLICATION ONLY Building 78-105 CALLE ESTADO Address LA QUINTA, CALIFORNIA 92253 Owner AA Anx3 scb 7T /Uc.o C,/�'J✓1A.P.Number BUILDING, TYPE CONST. S.F.D. OCC. GRP. Mailing Address 774-101-003-1 City Zip Tel. Legal Description Lot # 3 - B l k 19 5 -Unit # 19 Contractor Project Description New C o n s t ru.c t i o n of S i n g1.e Dennis Rickenberg Address family Dewelling 77600 Delaware City Zip Tel.. State Lic. City . A Classif. Lic. #i 811 Sq. Ft. No. No. Dw. Size 1630 Stories 1 Units Arch., Engr., Designer New Add 0 Alter 0 Repair 0 -Demolition 0 Address Tel. City I Zip I State Lic. If LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am ncertsed under tlrovlalons of.Chapter 9 (oommencing with Section et� ion 3 of the Business and Profeesiorm Code and my ifcense is in full force and SIGNATURE DATE OWNER43UUJM DECLARATION 1 her afttln that I am exempt from the.t.ordractoes License Law for the following reason (Sec. 7031,5,Busbress and Pn*sslats G\ds: Any city or county t which re9uies a permit to constru ager, btprov% 1 9 f or repair any Structure, prior Its issuance also piorlsbna rt lafor such - N to r; (Commestatement thatncing with seis ction 700%50 Mon 3 of the Business and'Proftssions wda ar Utet.he ra susept Therefrom, and the beats. for the aBeyed wxenpf L Any rbala0m of Section 7031.5 tty' any eppacent for PerMf sutOods rhe appdcantto a dve penally of not more than lite hundred dopers ($500). 0 1, as owner of the property, or my employees with wages as Meir sole compensation, will do =and and the structure is not Intended or 1V (a sale. (9ac. 11044, Buferteas arhd Profesaiona Cods: Time Coimrador>; Lfcarrse Lar does Tier aPptY to an owner of Property who IN or knProves therson and who does such rorty hinsef or though Ips own etgployees, provided Rrad sack brprosenwo are not Intended or offered for sale. N, however. the Widths or inprovenrent ld sold wMd one year of oonp& F, the owner4u0der wS hors the Wirdan ofproving that he did not build or irprove for the purpose of sole.) CI I, as owner of the property, am exctusivelyconfrecgng with Iicensetl contractors to xron struct the projecL (Sec. 7044. B�sess and Prcfe®slora Code: The Contractor's License Law does not apply to an owner of pt perty-who bu9ds or btprorea thereon, andwhocontracts for such pro)eds web a contractor(s) 6eatsed Pursuard to, The Canbactoes License Lew.) 0 1 am exempt.under See -----R & P.C. for this reason Date owner WORKEW COMPENSATION DECLARATION I thereby affirm that I have a certificate of consent to self rtsure, or a certificate of Worker s Compensation Insunv xk or a certified copy thereof. (Stec. 3800, Labor Code.) Policy No—company 0 Copy Is filed with the city. O Certified copy is hereby furnished. CERTIFICATE OF EUMPTION FROM WORKEW COMPENSATION INSURANCE (This, section need not be carxpleted 0 the Permit is for are hundred dollars ($100) vahadon or loss.) . I certify that in -the perfonmanoe of the work for which thispermit Is Issued, I shall not employ any pers�� in any manner so as to become subject to the Workers' Compensation Lavre of Calitonhia. Date_Owner NOTICE TO APPLlCANr: It, albw rhe" 9 fMe CsrL %xft of Exemption you should become atAW to the Moment, Cor p�Con provisions of the Labor Coda. you must forthwith convoyIrM arrcit prehilslorss d Odepenoi sAaff be dsomae revoked. CONSTRUCTION LENDING AGENCY I her attfm that there is a construction lending agency for the performanceof the work for which this permit is Issued. (Sec. 3097, [Svc Cads.) Lenders 'N Lenders Address_ This is abuilding permit when filled out, signed and validated, and is subject to expiration t work thereunder Is suspanided for 180 days. I certify that'l have read this application and state that the above information is correct. 1 agree to campy with all city and county ordinances and state laws relating to building xxmsbuctlon, and hereby aulhortae repro of this city to enter the above-- mentioned property for Inspection purposes. Signature.of applicant Date Mailing Addreas— City. state, tip FINANCE stimated Valuation PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL 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: � COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH As0000=l Parcel No: ENVIRONMENTAL HEALTH SERVICES 177q A91 — 001- PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn.to County speculation as Indicated on the attached check list. A non-refundable filing fee (see.below) is required when the application is submitted. Check must be made payable to the County of Riverside. Approval of this application shall remain valid for a period not to exceed one year from date of approval. Q VERIFY ITW8 IN SECTION A FROM SUILDNG 6 ,SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG s z O -Agent, Cartrector„Conticip rte, [ Phone Address &;Phone Owner Phone Mailing,Address Xft- �� ZIP Job /Tv" Address l:eOal DescrlPtbn Prop. (PM, 7iact; Lott Lot size ' use of Permit Pip, CU, Q Qw,Opme / /G Y 6'0 k..�DweUing, , eEc signatureof Applicant c} ~ Date CATEGORY: REV'.CODE FEE CATEGORY: REV CODE FEE Lam' SUBSURFACE DISPOSAL 1236 ❑ SITE EVALUATION UPON REOUESr 7349 $4200 m I7 MULTIPLE PARCELS WITHIN SAME (NO PLOT PLAN) z LAND.DIVISION' ❑ SEWER/SEPTIC VERIFICATION 7348 $11.00 Q a let 4-Paroele (Each) 1238 $45.00 (LOBS thorn 1 year1 b. Each Parcel alter 4 7344 $76.00 ❑ PRELIMINARY ELECTIVE 7352 $45.00 W ❑ Rereview (2nd review same parcel) 7344. $16.00 EVALUATION (Attach DOH SAN 53) W ❑ Site Evaluation in Conjunction with, ❑ HOLDING TANK 7351 $45.00 Critical Area 7346 586.00 ❑ ALTERNATIVE/EXPERIMENTAL 7345 $132.00 ❑ Site Evaluation Lot Less than SYSTEM 10,000 Sq. Ft 7347 $88.00 DATE Holding Tank Agreements: Completed ❑ Yes - b - CertMcatlon of E)d ding S.D. System.Requlred ❑ Yee WOCB Clearance required. (Aliso Fano ❑ Y" DOH SAN 007,.Santa AnaRegion Only) Solis Percolation Report Required. ❑ Yes No Special Feasibility Boring Report. Required. ❑ Yes Detailed Contour Plot Plane Required (1 to 5 R.Interval) ❑ Yes Other ❑ Yes Staff Specialist Lot inspection Required ❑ Yes No Lot Inspection Dame. Sore boring report by hx e. Date Sone Map Page ' Soil TypeMPfaed by _ Dams 4b U Na gf sollems T of s) No. Dwelling Units! (1) Septic Tank Sot Rate Greess/Ssnd O �N i��Tbnk O tTedroom0. Intcp ill JA ), each Line Sq. Ft Sklews(ballower a 'Install Une(s). R'bng _� wide with Leech Bled sq. ft. fA urea R mdN s4 R min: ainlnee ar .Per nirhning ft �� 'E j LeschlhreaAmd special design for elope: (3) Pit Diameter No, Pits" PR Below Seepage Pk TSI Depth O&W. APPlloebleInlett�(81) � /F ' '' ` WA overburden factor am / / ( hbx. / v Dom'"' No. 2 System /V//, - REMARKS: This appil ED,fortis category checked in SECTION B above; regarding the design of a subsurface disposal system as indicated on the imA , using the requirements set forth in SECTION C above. A building permit Is necessary for the installation of the OZ above-designedth system. No construction Is permitted in e required reserved 100% expansion area (1 ,Septic tank and sewer lines must be 50' minimum from any wells Leach lines must be 1 minimum from any wells, including expenailareflQ 3) Seepage pits must150' minimum fro any wells, I' uding ex n, area l/� `� ca4oN aftk_ 5-9 h Signature of Health Official L✓• i`- _ /6�'J bate RECEIPT NO. ` T /v Issued By Date -6 `16 of DISTRICT: ❑ Riverside, Indio ❑ Hemet,. 17 Perris ❑ RanchoCellf. ❑ Blythe DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINY-131dg. Dept GOLDENROD - Plans/Records Desert Sands Unified School District CERTIFICATION OF'PAYNENT OF SCHOOL FACILITY FEES -8� TO: City of La Quinta DATE: 7 % Department of Community Development 78-105 Calle Estado La Quinta, CA 92253 NOTICE: THIS DOCUMENT CANNOT BE ®UPL.ICATE®C. This is to certify 'that� , developer of -which is located at, within this District, has paid school.facility fees imposed pursuant to the authority generated by Government Code S'ec.tion 53 80 in the amoun of s 5 c S /w ) covering a total of 16 -i!) square feet of ( ) residential or b ( ) indust-xial/commercial development and that building permits for this footage in this development may now be issued by your jurisdiction. for DESERT SANDS.UNIFIED'SCHOOL DISTRICT White Building Department • Yellow - Facilities Planning • Pink - Accounting • Gold - Developer (10)-37 I . . E. LE01+ SPAt;ry of >f,i rips 01111,E or rp:on` nrAll r AGLII�UL I URAL CU�ImIS- 510"LII )AMES o VALIACT ��s�s1a%l rq:a:nssnr�ta AND CEEMENI6I.NVEMSIE i t j� M W.I:ICi111 S i 1AEASURL.5 SUM Ilwy 06, Ilul.te 11-12 'Cvnchelln, CA 92ZJ6 fr� .a4 V11'l'E JwN t LWELIUVE t' S 1 WW -1 CASE War wveloperl After reviewing your larltiscu111.11q II1f111!I, till Igo`Ilellallt tValley.151CdIn llot substitutlulls violatlon o[ yuarflnthle lu49 tloveinlny 111" �V� tills oLtice must be 110tified do occur clivi they dl[[er Crt.111 plant nFaterlul listed. —11 t 1 �tu1 a e y • do you Lor prutectbly fend IlLeserviny the Wadie Ila Valley's vest-[ree ellviroln>el1t. 'That y A cul.Eutal Ca�iit� ss�viier s UL [ ice ccl lndlo Euld Itiverside UE1.1ce. Or Ii Buena Engineers, Inc. 79-811 Country Club Drive, Suite 4 _ Bermuda.Dunes, CA 92201 - (619) 345-1588,/.328-91 31 Client Name Client Address Client Phone DATE JOB NO. ., 3-�i��s�-P� -PROJECT REFERENCE CURVE �.T S Cv -15' V eX COJ ATION . MAXIMUM DRY DENSITY IbsJcu. ft. v` T, CONTRACTOR OWNER WEATHER. _ _--. TEMP.___ oat _-.- -AM. (-e(V-I C4. Gat PM PRESENT AT SITE �U G TEST NUMBER TEST LOCATION LOT NO. ELEVATION FIELD TESTWG REFERENCE CURVE MOISTURE` CONTENT % DRY DENSITY lbsJCu. fL MAXIMUM DRY DENSITY % MAXIMUM DRY DENSITY IbsJcu. ft. OPTIMUM _l MOISTURE CONTENT % DS 13rt, 14.0 /16,-7 47'3 12<.c I J REMARKS: a� r 1 � _ S" uc ' L✓� ���� �iSk'� o Qrv� l0 . �( 0. t_,. � CLIENT REPRESENTATIVE AP'R-27-2004 TE AM Plan Number Sample Group Number Sample rise Number wider, TG_J-/�SsaIGS Street Address: ZZaQ Aeftl f r _ _ City/Stete2lp: ZW OwgA Cd 9,22S 3 Coples.to: Builder, HERS Provider HERS R T R The house was; grTested C3 Approved as part of Semple testing, but was not tested As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form coy with the diagnostic tested compliance. requirements es checked on this form, vDistribution system is fully*ducted'-(I.e., does not use building cavities as plenums or platform returns in lieu 1 ducts) Where cloth backed, rubber adhesive duct tape Is Installed, mastic and drawbends 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 (0 25 Pa) values Test Leakage Flowdn CFM If fan flow is calculated as 400cfm/ton x number of tone enter calculated value here If fan flow is measured enter measured value here �/s Leakage Percentage (100 x Test Leakage/Fan Flow) =. Check Box for Pass or Fall (Pass=6% or less)_ ❑ Pass Fall 1 l�J THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent Yes 13 No Thermostatic Expansion Valve (or Commission approved r equivalent) is Installed end Access Is provided for Inspection ❑ Yes Is a pass Pass Fail ❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT t. O Yes O No ACCA Manuel D Design requirements have been.met (rater has verified that actual Instellatlonmatches values in CF-1R;and design on plan. 2. O Yes 0 No TXV is installed or Fan flow has been verified. If no,TXV, vedfled fan flow matches design from CF -1 R. Measured_ Fan Flow = ' O D Yes for both 1and 2 Is a Pass Pass Fail