9908-053 (SFD)LICENSED CONTRACTOR DECLARATION
4 hereby 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
(signature of Contractor J
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.
rartiT.;� .
(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 agre? thatlif I should become
subject to the workers' compensation p -o isions of Section 3700 of the Labor
Code, all forihwi�pp
omply with those pr vis on
ate: ! llcant'� A t �""""•�
Warning Fail a to secure Workers' Compensation co erage is unlawfu 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
const�ction, and hereby authorize represerntatives of this City to enter upon
the bove-mentioned pr`bp rfy for-inspecti n "purposes.
Signature (Owner/Agent)'' "^ r M } Date4'h
PERMIT #
BUILDING PERMIT
DATE ��VALUATION J���6tiFY LOT TRACTJOB
SITE
ADDRESS :n�:;l�d )�it1?N�7��iTy6tl�7�
APN
OWNER
DESIGNER ENGINEER
CONTRACTOR /DESI]G/f
pA ``
��hh.4{
i.0
VO Wt,R.DLOW t'.IRCLE, Pi,R3` E OU
t,'f.lRUNA C" A �)S —,V)
OYK Nik CSA 9010
USE OF PERMIT
SIN"'J .'' VAt>'.tILY DWELLING
aD- ) k 48,, PLAN 4 PaM r DibiS NOT H4C,,L(3 k ail t7t~:K WALL OR
POUL,. I9°0 kFDV(_130N ON MAN CHI;,C K kliH UR NIU "'iPI-E tSSUAAN" 1
Or, SAME K At4 TYPF.
c~L ��4nia4 s~� 1 U id _rli�r 2971.40 Sr
300.00 .1W
0K fINk'Y, It I':� 1)1C%I+Y.Y, OF CQ`,'No J.AtI r17.`Z N
74131" 139
d�ECsS(�tia.� � 9!A`+BFs 'D 7f 1.�"�2vSlFd�T�
('ONS°3°R41t"'t'(0tdFEE, 101-(r(ft.!4i8-t.)i30I,.f6A.lac
WCAN ("M -CK O'F'F, In)414Af�ltnl!et• 41f?-�18
'10
X01-00t)42(Wcl Y
mdlVLA1Nt # i
f'i'rth dirt wyrToN T.v p ., v t� (n i -Offl.� 41-nfitii , x
' f,1},r�nsiat� T'°r:;:; �:�t • c?rft) <���- �°�.:� dJ'f!
Alt, '+` I P 0 6LtC`' N.A.1,15.',iRW,Si V, 7 1-40-2 i,5-o,'(i
LD• -P tdh1. PI -A UMPAI: d° FEE'
J
1
t
'Vf
RECEIPT ",
DATE
BY 1
DATE FINALED
INSPECTOR
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 p
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 Cz
POOLS - SPAS
BLOCKWALL PPROV LS
Steel
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
08/30/00 10:56 FAX 71.49211631 A1.11ance.
[?]17
Installation Certificate: Residential CF -&R
Use of thio form to satisfy the requirements of the Adminlatrative Codo Is optional, but the Information must bo provided and posted.
LOT *Al 60-A22
8112 Address P4ratt t Nu rn bar
An Installation cendicate is required to be posted at "the building, she prior to the issuance of the occupancy permit. This farm
may be used to meet these requirements. All appliance Categories listed below are the actual equipment instated. Note that
the efficiency and type of the appliance installed must be equivalent or better than the appliance specified an the Certificate of
Compliance (CF -1 R). This certificate (or its equivalent) shall be prepared and signed by the person(s) assuming overall
responsibility for the appliance installation.
1, this undersigned, verity that the equipment fisted in the category above my s{gnaturs is the actual equipment Installed and
that the equipment insets or exceeds the requirements of the Appliance Efficiency Standards. In addhion, I have 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.
HVAC SYSTEMS f
Note: Hydronic boiler information in entered here. Other hydronic.or combined hydrbnic equipment is fisted under
Water Heating Systems.
Heating Equip.
Type (i'urnsca,
hist urn ate.
CEC Certflted
Manuf. Make &
Model Number
Actual Distribution
Efficlency Type and
AFUE. sic.)Location
Duct or Heating Load
P1 Ing Before Over.
R!%lue SIZInS J131uhl
Heating
Equipment
Capacity Btuhl
�
pour/
=�.M� � % I
O, oc
.d.�
Lr- �c
CEC Candied
Cooling Equip.
Type (err cond.,
Conlpresaaor Unit
f►Manuf. Make A
Actual Distribution
Efficiency Type and
Duct or
PI Ing
heat purpip,etc.1
Model Number
SEER Location
R -Value
U
AIS_ COrff"tanda
�
�2. U
Z
Th w ng designesign
'h Ener Eflle
hest gain rate have been determined using a method spec!led in Seaian 150(h) e(
nd are two ofcriteria used for equipment sizing and selec on.
Signa yr
ACU6NC1; I�FCHA_NiC_,4L U aT/Nc f mr, AI(,
Data HVAC Subontrac%x (Co. Name) or Ge -stat Ccntracxr or Cwner
WATER HEATING SYSTEMS
Water Heating CEC Cartff led Rated' Tank Er for o External
System Type Manut. Make & Input (kid capacRy Recover Tank
{storage gas, etc,)
Model Number tY tsndby' Insulation
Or Btuh► (gallons) Efficiency Loss f%', R•Value
t, For smell gas stoiagi (rated input 5 75.000 Blta/hr), electric resistance arta meat pump water heaters, list Energy Factor.
For large pas storage water heaters (rated input >75.000 Stu/hr), list F,atec input, Recovery Etficienci arc S,anc_y Loss.
For Instantaneous gee waist heaters, list Rated Input and Recovery Efficiency.
For Instantaneous electric waist heaters, list Rated Input.
FAUCETS i SHOWER HEADS
All faucets and shewerheads installed are fisted in the Cormtsslan's Dlrectery of Cenified Favcsts an,c ^',cwrrheaas,
pursuant to Title 24. Part S. Subchaolor 2, Section i i.t.
Signature 0a:e
;IYIW January i9r2
Plurnoirp Subcontractor (Co, flame i cr Gdneror Contraccr or c`.ner
;)
08/31/2000 ' 08:47 9092920499 , SCHMID .CON?RACTIhi!a
FADE 15 ,
,I..
' This is to certify that insulation has been installed in conformance with the'currenttene re ulation,
�JY 9
.Y
California,'Admini ,
stratiJe Code; Title 24; State of California, in the building at
' =1 _ ♦ PGA WEST) PHASE 1A / TRACT 289601 LA QUINTA.
LOT 48
CEILINGS: t " . •,
TYPE: Fiberglass BATTS 'MANuACTURER: Owens/Corning y TWiCKNESS: R-38 12" BLpW
WALLS:,'-. r _
r
rr
• TYPE: Fiberglass Batts MANUFACTURER: Owens/Corninc THICKNESS:R-13 3 112"
• t ,
`♦;
GENERAL CONTRACTOR: CENTEX t'OMES'.r - .LICENSE:
},
i BY. TITLE: t'
+ - i . - . ..
s
•.�
_ SCHiMID INSULATION CONTRACTORS, INC. t LICENSE #221517 _C-2 4
' BY: —TITLE.- PRODUCTION MANAGER DATE: 08/30!00.
*.
�JNSULAT'ION CERTIFICATE y
" This is tccerlify, chat♦insulation has been in stalled,in.confo•rman' ce with tFie current
energyregulatiori,
located'at
California Administrative Code, Title 24, State of California, in the buildingA.
-
�'
• r ,
PGA WEST 1 PHASE 1A 1 TRACT 289,601A QUIhITA CA
`CEILINGS:
TYPE: F'ib;Erglas5,13ATTS MANUFACTURER: OwenslComing. `� THICKNESS- R-38 1.2" BLOW "•
�'
is
_
i
. .. .11 Y
'✓VALLS: y -
•
;
TYPE: Fiberglass Batts' MANUFACTURER: Owens/Corning ".THICKNESS: R=13 3 112"
GENERAL CONTRACTOR: CENTEX HOMES,, I• LICENSE #
BY: TITLE; r
.. .. 4
-
SCHMID INrCONTRACTORS,'INC. ' y `' LICENSE #221517, C-2
BY: • TITLE:. PRODUCTION MANAGER DATE: 08130/00
` T '
FAX NO. 'u l . 27 24" 10:.311 '! P?
u., L
It Aj�A 11V1N l.J1�111' IL ATE a�& of %) CF -6R .
Vdd
tris e m r Number .
An installation certificate is required to be posed at the baildinS site or made available for all appropriate inspections. ('ibe
information provided on this form is required; however, use of this form ta.provide: the information is opdonal.) After
completion of final inspection. a copy must be provided to the building department (upon requr.st) and the building owner at
occupancy, per Section 10-103(b).
HVAC SYSTEMS-
Hearing Equipment
Equip• d of Efficiency Duo Duct or H"a ng H"W$
Type (pkg. CEC Certified Mfr Nance Identical WUL etc.)' 14Ca600 Pip n Load Capacity
heat DMP) and Model Number Systems =-IR value) (attic. etc) R -value (Daft (BtW1tr1 ..
Cooling Equiprxrcnr
Equip. CEC Cmlrlcd CoMpmmr 0 of Ef6deuey Dun Cooling Cooling
Type (pkg. Unit Mfr Name and Identical (SERs, etaJ' I-vcsalotr Dwt Lead capack
hes 1 Model Nurnbcr Pecr-IRValvol Lqtdc, etc) R-Va! l
1. > reads greater than or equal to -
1.
o1. the undersigned, verify that equipmem listed above is; 1) is the actual equipttteat installed. 2) equivalent to or more
efficient than that specified in the certificate of eompl"sauce (Form CF -1R) setbtnitwd for. compliance with the Fj err-
40idency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requimnentn for
manufactured devices (from the Appllanm Ericiency Regalarions or Part 6), where applicable.
ignaru=. Date
InsWling
Suboantraczar (Co,Name)
OR General Contractor (Co. Name) OR Owner
WATER HEATII\'G SYS -MMS;
Heater CEC Ccrtiflcd Mrr
Distribution If Recir- sof
Typc (Std. culation. Identical
Ratedt Tank
Input (kW Volume
Em-
ciancy3 StatWW
Esaenad
!.-mlatlon
Type Nam & Model Number
Pointof--Usa) Commi Syatettts
or Moo) (allotts)
(>'�, RE) boss (%`
R-Walucr
ryas s7,7,77tm
K-
.o
2 For rtualt gas ttoragc (rated input oriess than or equal to 73.000 BtWhr). ekLarie re istance and beat pump -awr heaters. Itu Encrgy poem.
For large gas storage wamr hares (rated input of Vv4tcr dw 75.000 Bta tr). list Roovesy Eirciertcy, Srandby Loa and Rated Input.
For instantaneous gas water beaters. Ila Recovery Efficiency and Rate41".
3. R-12 extemal Will orlon is mandatory for ttasge water heaara with an a uuv factor of las than o.Si.
Faucets & Shower Heads.
All faucets and showerheads installed are certified to the Commission, pursuant to Tide 24, Part 6, Section I 11.
I. the undersigned, verify that equipment listed above my signature Is: 1) the actual equipment installed; 2) equivalent to
or more efficia,t than that specified in the certificaw of compliance (Form CF -1R) submitxd for compliance with *9
Energy FffiC1c12Cy Slwzdards fbr residential btn7dings; and 3) equipment that masts or exceeds the appropriate
require:me n4 for manufactured devices (from the Appliarme Effkiency Regulations or Part 6� where applicable.
0 oo. JD Mechanical, Inc.
Signature, Daic Installing Subcontractor (Co. Name) OR
COPY TO: Building peparunrnt
General Contractor (Co. Name) OR Owner
HERS Provider (if applicable)
Building Ownerat Occupancy
July 1. 1999
- {.. "'� - �. any � J.t�`*'�,��. i:. .r f�;,� 1, - r '�. t � � IF
�'t.• �i��: �' .. - � 4, � i;
�a Ownte�y� Ap%cupqpcly
ta, rI• { 1 U �"u�i,
MD
ild1hnd'iaD6partent M of
This Certificate issued pursuant to the 'requirements ' of Section, 109.. of, the Uniform Building Code,
certifying that, at the time of'issuance, this structure was in complcance with the various ordinances .
of,the''City.regulating.buildingpconstruction' or use. For the follbWifig;=
BUILDING' ADDRESS - . l't� k 80-499 SPANISH--bA'Y•
s {; ,
Use'Classification: SINGLE FAMILY D_ WELLINGBldg ;P,4rmit. No.: 9908-053
Occupancy: Group: R-3 " yType sof :Construction: -VN Land�Qse:Zone: RL
K-:
Owner of Building: CENTEX HOMES-. <' Address: 2280_'WARDLOW CIR. STE 150
if
i • City: , CORONA, CA., 92720
By; DANIEL P. CRAWFORD JR.
Date: 9/28/2000
t. ,
Building Official-', ;
POST IN A CONSPICUOUS PLACE �-
j -
t t, r!'T