0304-321 (SFD)LICENSED CONTRACTOR DECLARATION
I 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
760335
Date "' Y Signature of Contractor
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 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 insurancecarrierr& policy no. are:
W"IT
Carrier TF. F1i3NRD Policy No. . !608.9£?1.011
(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 agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with t0ose,provisions. �.
Date: ! p _16Vt,,Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City.of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for.in ection purposes.
Signature (Owner/Agent), Date
PERMIT #
BUILDING PERMIT
a
DATE VALUATION 'LOT- -14' ! TRACT 914'JOB
SITE
ADDRESS fl;?' 17x eg%r. �63YYCpwt: � ':Fr R,
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
s m at3J-Xe VV ', Lp
O�RAPANY
5141 AVENllaATaNG t.0.•0
a1
09
yL"+: p q/
IARAD
t160)504-158618 9Kr 3376
USE OF PERMIT
2ANGUR F,F1'kIXTY DV L,L KG'
a .' id • I A. , .ILI PUK—P -.7 is 1-J . E ! :.a7, :.s vrvr a d.+iw• i irr sa ws,, ur r�iJ .�
PON4 00'NA OR 74%1ZRSb?xfCTX.314 TO 111,,01 CHECK
M. ia`Jtar TO MUL.TVVt t,F 154WIt NTCR Cie SAi'1P..} PLAH T'Y13F,
t
i�i�ltCli�PA1'iQ 57.x.04 sur
Q A1MCbi?$C.` RPORT $Xop OF
PaIA41 "ITE, WATMARY
GC�1 fiTR�1�.'1';(ta?n fi3? ; '1'01-0��{Y•4�y.F LSf)C! Z111066,30
PLAN C�HECX ME, W?Al
MKc.HK N1CAL FZ101-M-421-000
1SLEC .tCCAL,IT ; pt)1 4 4X3,24'.(8()43 $!35.71
l'f,UKDRIG ME X4'1. -000.419 -(dib
S"±`tt!Okat9 �Csx1�� prtr;� . �.►'�"tri 1411-�4313"2� �-i3t34'r �aa.7'� .
ORAL R40 F 301-000-423.000 PSI"
' I`r.�VI�I;.ilF'EI�.Ylu1`►.��.�'� 1??r�; �'�,9tc3:c�
ma IRI 1''yJ:ouc 1a�u-CES • PORI 270 -JW -415-000 $52,9$
MOB PRE -11.41D FI 'S $0,00
HOW
TIAN10
I -
C!T`!
F-I!+lIAF:CE' DEPT
RECEIPT
DATE
BY
DAT NAE
PECTOR
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
. (• 03
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
*
Compressor
Insulation
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
BLOCKWALL APPROVA S
POOLS - SPAS
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
Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection _ :
D3
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
(V U)
W
O=) M
r— CiLr)
�W�
�Zt�
co
JV(0
rn
Z
M
N
O CV
0 °)
�a
Z
L0 0
0 J J
m U U
O
� 0)
NtZ
ob Z)
�0
Q
J
LICENSED CONTRACTOR DECLARATION
I 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
760335 B 3/31/05
Date Signature of Contractor
OWNER -BUILDER DECLARATION
1 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).
( ) 1, 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 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 STATE FUND Policy No. 1608301-012
(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 agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage 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 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT
0304-321
DATE VALUATION $221,137.40 LOT S4 TRACT 29147-2
JOB SITE ADDRESS 57-775 SEAUNOLE DRIVE
APN 762-380-013
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CRV GOLF WEST, LP
ASHBROOK DEVELOPMENT COMPANY
5141 AVENMA ENCINAS
5140 AVENIDA ENCINAS
CARLSBAD CA 92008
CARLSBAD CA 92008
(760)804.6868 CRL# 3376
USE OF PERMIT
SINGLE FAMILY DWELLING
SFD - LOT 54 PLAN 2A PERMIT DOES NOT INCLUDE BLOCK ,
POOL, SPA OR DRIVEWAY APPROACH 75% REDUCTION TO PLAN CHECK
FEE DUE TO MULTIPLE ISSUANCE OF SAME PLAN TYPE
a 00 1 Cm1DIES
CUSTOM CONSTRUCTION $615.00 SF
PORCH/PATIO 525.00 SF
GARAC}E/CARPORT 534.00 SF
ESTIlVIATED COST OF CONSTRUCTION
221,157.40
PERMIT FEE SUA/IMARY
CONSTRUCTION FEE 101-000-418-000 $1,066:50
PLAN CHECK FEE 101=000-439-318 $217.42
MECHANICAL FEE 101.000-421-000 $111,00
ELECTRICAL FEE 101-000-420-000 $135.71
PLUMBING FEE 101.000.419.000 $181.75
STRONO MOTION FEE - RESID 101-000-241-000 $22.12
GRADING FEE 101.000.423.000 $15.00
DEVELOPER IMPACT FEE $2,405.00
ART IN PUBLIC PLACES - RESII 270.000.445-000 $51.89
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,207.39
LESS PRE -PAID FEES
$0.00
TOTAL PERARIT FEES DUE NOW
$4,207.39
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
Demon C A B E C
Ef VERGY --
Po. box s29 F%/Foxl7W WAQV a
Rancho Mirage. CA 92270 Ce11: [761718 2.�0-1�5�
Email: RKrcwn6237CQa0l.com
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
Ph e
Pro 'ect Title Dt�►bR.ala
rojec Address Y / Builder Na a .Z
uc 1 11 11
B- u e Contact Telephone tan Number
H a Telephone Sample Group Number
m mg gnature ee to amp a House um er
Firm: C� ���lt���V a��yo � °� HERS Provider:
�y441-11E-e-F-°S-
Street Address: �0 Ip�� City/State/Zip: KAt��ND Illy •g�2�c>
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 comply
with the diagnostic tested compliance requirements as checked on this form.
[Er The installer has provided a copy of CII (Installation Certificate.
ErDistribution system is fully ducted (Le, does not use building cavities as plenums or platform returns in lieu of ducts)
Q' 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 connect ions.
r
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 —L– —
If fan flow, is calculated as 400cfm/ton x number of tons enter calculated
value here Q
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fail (Nass=60/6 or less) ' 0
Pass fail
THERMOSTATIC EXPANSION VALVE (TXV)
Thermostatic Ex n5ion Yalvc is installed and Access is
2r
❑ No �� ❑
provided for inspection
Yes is a pass Pass Fail
0
•
D -r
r t�1•L
ENERGY= A o E C
sw%ic
P.D. Box 629 Ph/Fax [76015642044
Rancho Mirage. CA 92270 Cell: (760) 8094"M 250' IbSZ
Email: Wrown62370aa&com
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -411
Title '
. 14
n . �>psa. c�ve•N
Address
Contact Telephone
AIN 2
Rat Telephone
— -t--
°e
9'�'/
Builder Name
3'� PLS �o�
e flan Number�
�teoi9� �
Sample Group Number
Samp ou a um er
a
Firm: �1ES�Q HERS Provider:,-t�•���-�.
Street Address: 9 E6% % 1 City/State/Zip: IdaTl® 1 c •g.R°lx®
Copies to: Builder, HERS Provider
HERS RATERS OMPLIANCE STATEMENT
The house was: LTJ 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 comply
with the diagnostic tested compliance requirements as checked on this form.
The installer has provided a copy of CF -6R (installation Certificate.
OR"Distribution system is fully ducted (i.e.. does not use building cavities as plenums or platform returns in lieu of 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.
IJdooMtNIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage,Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM Q 25 Pa)
Test Leakage Flow in CFM
if fan flow is calculated as 400cWton x number of tons enter calculated
value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) =
Check Box for Pass or Fail (Pass--6or less)
value3
AV—
Pass
b0
Fail
WrHERMOSTATIC EXPANSION VALVE (TXV)
1
19 Yes ❑ No Thermostatic Expansion Valvc is installed and Access is �,,, ❑
provided for inspection
' Yes is a pass Pass Fail