9909-281 (SFD)LICENSED CONTRACTOR 'DECLARATION..
l.hereby affirm under, penalty of perjury that I am licensed under rovisions,of
�4AI! Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04W Professionals Code, and my License is in,fulj force and effect.
O M License # . , Lic. Class Exp. Date ,
CY
• w 8r i
Z Date i $Ignature of Contractor
C)O�
CO
OWNER -BUILDER DECLARATION
W .W I hereby,affirm•under penalty of perjury that I •arn exempt from the Contractor's
l -"a License Law for'the followin 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 riot -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).
<0O I am exempt under Section B&P.C, for this reason +
N Date Signature of -Owner
O� ;
Q WORKER'S'COMPENSATION DECLARATIONCL
,_ s
p IM I 'hereby affirm under .penalty of perjury one of the following .declarations:
Lin. O (.) 1 have,and'will maintain a, certificate of consent to self -insure for workers'
' X W L compensation, as provided:for by Section.3700.of the Labor Code, for the
O • � .Q ' performance of the work for which this permit.is issued.
Q .0 (�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
CL .� F- permit is issued. My workers' compensation• insurance carrier &. policy no. are:
zt z Carrier Policy No
nAAVV-u.
CO :-
iwertr+aWi�nrttY+t9a:r4r -vrw.
.
Cy
—J.
(This section need not be completed if the permit valuation is for $100.00 or less).
O I'certity that in the performance of the work for which this permit is issued,
„ I -shall not employ any person' in any manner so as tor become subject to the
workers' compensation laws of California,: and agr a that if I should become
subject to he workers' compensation,provisi • ns oflection'` 3700 of the Labor
ttCode.l shal ;f 1 hwith comply-* ith those ps
Date`:" '
'X -)Applicant
L arning: Fature to secure Workers' Compensation cc erage Is unlawful.and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for.in Section 3706
of the Labor. Code Interest and attorney's fees.
IMPORTANT .Application is hereby made to the Director of Building and Safety
for a permit subject• to the:' conditions ..and 'restrictions set forth on his
application.
1. Each person upon whose,behalf4his:application is'made & each •person at
whose: request arid for whose. benefit work is performed under or pursuant to
any permit. issued as a result of.this'applicaton.agrees`to, &. shall,. indemnify.
"& hold harmless the .City of La Quinta, its officers, agents and employees:
2. Any -permit issued as a result of -this. application becomes null and void if
work. is not• commenced; within 180' days from date; :of ,issuance of such
permit, -or cessation of work for .180 days- will subject _permit `to cancellation.
I certify that I have read this application and state that the above information is .
• correct.. I, agree to comply with all City, and -State, laws relating to the building
construction, and hereby' authorize representatives of this Cify to enter upon
the'above-mentioned property'fo.r insp'ectionypurposes
Signature' (Owner/Agent)'
' -- PERMIT# - BUILDING, -PERMIT ;
DATE+�I,1�VALUATIONxti�+"'t1rZ 'LOT�Y: - TRACT,
�•�-
JOB SITE o., wj, . •-ir-i-. ��.. t�+
ADDRESS pS5.Ei1i�Aw' A J .!.
JAPN
t�
�9!»�k
�-
OWNER
CONTRACTOR 7 DESIGNER / ENGINEER
f?. ,)2i9-400() CEM:0 �'S761•
USE OF PERMIT
F'$g�--�����',�,77p:�.��.�,t%�:�t3
.wT
-
5-� 7�.7�,� p�rvS `�•,. � yt� ,} . ! ry
SVD- '1.O 53. ULAN 3, T°S7Y.tiAVSA 4 DO.E J` .iY( dfial.:d.is I-',.�:ti; 00% Wf'l+ L OR .. � .
&+t,K , :7.51:ti MJLTl1(,"A`lt° N is N ��t:.AN i"T.I.FX'X' .IX".1Gft ImmUl."�if?'11i 18�i�r� A1v>: 111 '
OF SAA°li3 2_'-43.AN'V6,+L
f c�'Ai1/\ 'r'Yi1i 'il•ICI'.I+ IR,h.' 1 ,tN W.W
`
53N.ejo SIF'
- �etaz.��:il::�i�r.~tta:►e'�'.. t+�sti:te� :S.s!� . '
ti�e� a tilt x trt�*y1 a �sr�tt spm+ a+� �t►rss� za� rs�a`vrtb; '
M'M1!!`�: ,t 8�1L
'4
�� rotes scb
Y !4?!"!f.t..•AtY
U19PiSf3it1C"fif3f.f•#3 @g.d3t3f?•4:Ek�li)'1.t9rf.#!p?
31
K
4,il to x�t1`a "eta i I ^1 OQ0 ;°1, } $1 i0AA1
UDMUCAI.-tip
Px
Pit;Faiftll�« ��� ir�l-fit�iD-41y'•f1f)t2 � �.�i�;.SU
$
�„.= r,,14
�rizra�vr.aarrn'serr�r tite�� )tat f3fif�af�f..�t�a�L.,
;
rRAM01".' LM, _ 101 400.9 423 -010_.'>
e•JP;i.IC. PLACES
AM
Yr.tia11 1°fir K, tYYDY' PT, A,fR°Yy:
$4,291 A0
y€t
..frS �ioah �F�v�' ali�,s.L,Y }•'°7�a�'
' - . "��.�v
:Imil`"FF.f"8O�,}�; i"! 0W
RECEIPT
DATE'
BY 1 }
DATE FINALED
INSPECTOR
-10^
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings _djj/L A �Q- 6
Ducts
Slab Grade
Return Air
_
Steel
Combustion Air
Roof Deck _�r IJ 4 4,1,d_
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing A&7 �Y
Insulation gy y�/y�
Compressor
Vents
Fireplace P.' .
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
DrWvall - Int. Lath _2
Final
Final _
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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 f Z
Pool Cover
Sewer Connection /' ��
Encapsulation
Gas Piping
Gas Test DO
A pliances
8 / /
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)
U3 "30/00 10:56 FAX 7149211631. A111ance
R111
installation Certificate: Residential CF -6R
Us* of this form to agility Ute roqulramenta of the AdminiotrsUve Code Is optional, but the InfarmsUon must be provided and posted.
dile Addrega - permet Numbvv
An Installation cdnificate is required to be posted at the building site prior to the issuancs of the ocsrpancf perrnrt. This form
may be used to meet these requirements. All appliance categories listod below are the actual equipment installed. Note that
the deficiency anc type of the appliance installed must be equivalent or better than the 40aRcs s&escified on the Certiecata of
Compliance (CF•1A), This canriicate (or as equivalent) shall be prepared and signed by she poerson(s) assuming overall
responsibility for the appliance installation.
I, the undersigned, verity that the equipment listed in.tha category above my signature is the actual equipment Installed and
that the equipment masts or exceeds the requirements of the Appliance Efficiency Slant ards. In �ac&)'O' n, I hays verified that
the eqmeRt is ®quiv3lent to or mare officiont than the equipment specified on the Cartiflcata at Ffllr'Omplianca subm tted to
demonstrate compliance with the Energy ciency Standards for residential buildings.
HVAC SYSTEMS
Note: Hydronic boiler irdermatron is entered here. Other hydronic or ccmbined
Walor Heating Systema.
hydronic equiorrart is Ilstod un der
Heating Equip, CEC Caetffled Actual Distribution
Type pumace, MEnul. Make & EMlclency Type and
Duct or Heating Load Haating
P1 Ing
haat um etc. . Modal Number (AFUE, etc. Location
t
Before ®ver- Equipment
R•Valu® BeSlLo Bver- Equip 8tuh)
�.
UG'r
' P17 j tWl
U7-
O nG�:
e T
CEC C.artiffed
Cooling Equip. Compreasoor Unit Actual' Distribut;wt
Type(sir
Duct or
Pit
heat urnoe c� Made! Number (SEER)
RLecstlon
lu
4
T b. dlnq a gn h lose and design host gain rate have been daterrr.,-rd ue,ns a ^t®;;,oc eget fled In SaGicr, 180(n) of
t' a En rgy It ren., tandards, and are two of the Criteria used for
equipment
-
sizing and sel; cxri,
/ ►':� ".H Amt l " A . 1�
Sign 're
Cate HVAC Subontracor (.Co. !Mame) or General Cont acar or Owner
WATER HEATING SYSTEMS
Water Heating CEC Certliled Rated'
System Type MBnut. Bake Tank
Energy External
Factor or tgnA
(storage gas, etc.) Model Number Input (kW Capgcity,
orBtuh) fgallorsi
Raccvery Standbyt Inaulstlon
Etilclenc
Loss(:1 R -Value
1, For email gse atoisge (rated input 4 75.000 Stuhr), elecirle roatatsnce and hest sump wetor hod tof it. :ist Energy Pactor,
Por large 94e storcg• water hoatera (rated inpt;t >75,000 Btu/hr;,
list Rmteci :nput,
list
For Instantaneous gas waist hestara, list Rated Input and Reetvery Elficienrf,
For
Recovery S,ficiena ane Starrby lose,
Inatantsneoua electric wale► host fist Rated Input.
FAUICETS & SHOWER HEADS
All faucets and shcwerheacs installed are listeo in the Commis:;or,'s Direr..: of Ca tied Fa �:: acwerneaas,
-. �.=,
PUM.'ant to Title 24, part 5, Subc'napter 2. Section 1 t t.
Sigr,arJrA I Date Plumbing St,beon,736tor (Co. Name; Gane:di CentracEat or ovine,
Rer:uc :atout ry 10 �2
08131 08:_47 9092920499: SCHMID CONTRACTING F'AiaE. 09
" •
INSULATION CERTIFICATE _
This is td certify that insulation has been installed in conformance ovith the cun'ent energy regulation; ;
Cahforn. Administrative Code, Title 24, State of-Califomia,'in the buiiding at
' PGA WEST 1 PHASE 2A 1 TRACT 289601 LA.QUINTA`
s s
LOT 53
.• `CEILING5: .
TYPE: -Fiberglass -13ATTS MANUFACTURER: Owens/Corning THICKNESS: R-3812" BLOW
WALLS:. n. »
.c {
TYPE:. Fiberglass,Batts MANUFACTURER: OwenslCornirig ,THICKNSSScR-13 3 112'' '
GEN ERAL CONTRACTOR: CENTEx HOMESLICENSE:- _
BY: TITLE.
SCHMID INSULATION 9ATRACTORS, INC: , .LICENSE #221517. C-2
TITLE: PRODUCTION MANAGER, DAT
E: 08/30/00
INSULATIONCERTIFICATE .
,.
1'nis is to certify that insuiation has been installed in conformance with. the current energy regulation,
California Admir,Istrative Code;'Title 24, State of California, in the building located at
PGA WEST/ PHASE 2A / TRACT,289601 LA QUINTACA
LOT 53 t r�
! r �.
CEILINGS:
TYPE: Fiberglass BATTS'MANUFACTURER; OvtrenslCorning THICKNESS: R-3812" BLOW
:,. VVALLS:
TYPE,.Fiberglass Batts':
"MANUFACTURER: Owens/Corning THICKNESS. -Al 3 3 112"
GENERAL CONTRACTOR: CENTEX HOMES LICENSE # r
BY:' 71TLE:
SCHMID 1NSl1LAION NTF'ACTORS, INC. LICENSE #221,517 C-2`'
BY. ITI:E: 'PRO • .
DUCTION MANAGER DATE: 08,(30/00
F.%m . t FAX NO.
u„ t AJL LA 11V1N L -s 1 lr' MLA-11;
yQs
iul. 27 24" 10:.31W P2
1 of 7) C k* -6R
A rens arm r NuMber
An installation certificate is required to be posted at the building site or made available for all appropriate iaspeaiotts. (The
information provided on this form is required; however, use of this form to„provide the information is optiooal.) After
completion of final inspection, a copy must be provided to the building department (upon request) and the building owner at
occupancy, per Section 10-103(b).
ffVAC SYSTEMS:
Hearing Equipment
Equip• r of Efficiency Dna Duct or nesting
Typhen 1pkp. CPC Certified Mfr Name Identical (AFUE ase,)' Location Piping Load Ca�v
Heat 1 and Model NumbW svg arta. etc.) R-vai
Cooling Equipment
Equip. CEC Certiried Compressor i! of F.ffici aey Dna Cooling Cooling
Type (pkE. Unit Mtf Name and Identical (SEER, tea.)' 1„ocatiorr Duct LOW}�
hent ) Model N F -IR v e) eta) R -value 1
I . ? reads greater rhan or equal ra
1, the undersigned. verify that equipment lined above is: 1) is the actual equipnumx installed, 2) egtuvale= go or more
efficient than that specified in the certificate of eompl”"tanto (Form CF•1R) submitted for. compliance with the EnerV.
Efficiency Standards for residential buildings„ and 3) equipment that merits or exceeds the appropriate requirements for
manufactured devices (from the Appliances E,llcieruy Regulations or Part 6), where applicable.
tgnamm. Date
WATER FfEATTNG SYSTEMS -
Distribution
Heater CEC Certified Mfr 'Type (Std.
Type Nam* & Model Number' Pointof Use
rac0_ M_<n
2 For small gu ttoragc bated input of less than or equal to 77.000 BtWhr). c[ectrie resistance and beat pomp -user haters. list Energy Factor.
For large gas storage water loaners (rand input of 6rtug dlut 75.000 Btn/!tr). Ilat Rvwvety Efficiency, Standby Lon and Rated Input.
For instantaneous ear water beaten. Ila Recovery Efficiency and Rated Input.
3. R-12 external insuh t!on is mandatory for storap inter hcatun with an energy factor of lass than 0.58,
Faoeets & Shower Heads-.
All faucets and showerheads installed are certified to the Commission. pursuant to Title 24, Part 6, Section 111.
I, the undcrsigncd. verify that equipment lined above my signature is: I) the actual equipment installed; 2) equivalent to
or more eff'iciazr than that specified in the certificate of compliance (Form CF -1R) submim ed for compliance with the
EnerV Fficien cy Srandanls fbr residential bmldingg and 3) equipment that masts or exceeds the appropriate
require:mencji for manufzwimd devices (from the Appliance 0xialry Regulations or Put 6), when applicable.
� , /, Fx",&f JD Mechanical, Inc.
Signature. Dar;. Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
_ July 1. 1999
s mg
Subzaniraanr (Co.
awe)
OR General Contractor (Co. Name) OR Owner
if Recir•
a of
Rated' Tank
EfFi-
External
cvlation.
Identical
Input (kW Volume
cianay' Standby'
!nsuladon
)nvol Type
Systcrw
or BMW) (allow)
(�. RE) Loss (OW
14 -value
2 For small gu ttoragc bated input of less than or equal to 77.000 BtWhr). c[ectrie resistance and beat pomp -user haters. list Energy Factor.
For large gas storage water loaners (rand input of 6rtug dlut 75.000 Btn/!tr). Ilat Rvwvety Efficiency, Standby Lon and Rated Input.
For instantaneous ear water beaten. Ila Recovery Efficiency and Rated Input.
3. R-12 external insuh t!on is mandatory for storap inter hcatun with an energy factor of lass than 0.58,
Faoeets & Shower Heads-.
All faucets and showerheads installed are certified to the Commission. pursuant to Title 24, Part 6, Section 111.
I, the undcrsigncd. verify that equipment lined above my signature is: I) the actual equipment installed; 2) equivalent to
or more eff'iciazr than that specified in the certificate of compliance (Form CF -1R) submim ed for compliance with the
EnerV Fficien cy Srandanls fbr residential bmldingg and 3) equipment that masts or exceeds the appropriate
require:mencji for manufzwimd devices (from the Appliance 0xialry Regulations or Put 6), when applicable.
� , /, Fx",&f JD Mechanical, Inc.
Signature. Dar;. Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name) OR Owner
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
_ July 1. 1999