0307-367 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
�thapter 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 _ 03,43112(
..Date%.EST 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).
( ) 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 I 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.
Se( ) I have and will maintain workers' compensation insurance, as required by
ction 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. 1602301-012
(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 �• rovlsions.
�D,ate: f/ / f u / n'*pplicant �i' s "".. '1
1 r r W - ,r
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'i '
work is not commenced within 180 days from 'date of issuance of suc
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. r
Signature (Owner/Agent) t---'"' -- Date
BUILDING PERMIT PERMIT /f
�
DATE . VALUATION LOTury
TRACT
29. 29147-2
JOB SITE tt•�•[
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
3140 AVRIWA Hi3'C°)NA8
S,1 40 AVMMA ]W(. AS
CAR LSBAD CA 92008
CArd-SI I3AD CA 92008
C160)804.6868 CD1.4 3376
USE OF PERMIT
8YMCITS FAWL°Y DLW.M1190
SFD • I.OT n, PI.AIS138R.. PERMITDONS. NOT INCI:WDE BLOCK
WA114% P004 SPA OR D.JUVEWA. i APPROACH
CUSTOM CONSTRUCTION 4801.00 .;]F
PORCH/PATIO mm sP
0ARA(3WARPORT 536.00 8P
XSTWXff,D COn OF C014MIXT.fC>.4,+i
236A?7.6
FERAW1W.�] ptr2 x
CONSTRUCTION FEE. 101-000.418.000 $1,117.00
PLAN CHECK FEE 1.01-000.439-318 5906.90
MjP.C.H"IC'AL VEE 101-000-421.000 SWO
ELECTRICAL 6` MR. 101-000•.420-000 �i6I.26
PLUMBINO FEE 101.000.419.000 31801S0
SPRC3NO MOTION FEE 'A RPSID .101 -000-241 -OW $23,64
CRADI1,IO AME 101-000-423-000 3i�.0ft
OEVELOPLR IMPACT F '
ART rN PUBLIC PLACED - R&S-1I 270-00'rP445.0.00 $90,04 .
SUB -TOTAL COhfMUCUION AND PIAN CHECK
$4,961.74.
US$ PRE -PAM FW,
$0XV
'�'OT,;;U, a'r3.t1s4"Sr FEES DUE NOW
11 4.987.74
20
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CIiY OF Ll� i3llf�l
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DAT FI LED
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INSPEC R
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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
- O
F.A.U.
Framing
li,J
Compressor
Insulation
3 Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
DrWall - In Lath
Z D
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
f G
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer ConnectionEncapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring —/ Q•
Low Voltage Wiring
Fixtures .
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Wily Notice (Perm)
COMMENTS:
WT -* 2`A 441,,`S •� �. ;�
Mart
ENERGY, C ADE C
P0. Box 621
Rancho Mirage, CA 92270
Email: DESNRG AAUL.COM
Ph/Fax (760) 564-2044
Cell: (760) 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7)
PASADERA PH -5 DATE TESTED 6-14-04
Project Title Date
P.G.A. WEST LA QUINTA ASHBROOK COMMUNITIES
Project Address
. STEVE VAN LUE II
Builder Contact
KROWN
Builder Name
760-801-3981 • PLAN 3 2 UNITS
Telephone Plan Number .
760-250-1852 GROUP 4
HERS Ratr!o Telephone Sample Group Number
#CCNRK613292 Jul 2 17004 LOT 29
Certifying Signature Date Sample Lot Number
—
Firm: DESERT ENERGY SERVICES HERS Provider: CHEERS
CF -4R
Street Address: P.O. BOX 621 _ City/State/Zip: RANCHO MIRAGE, CA. 92270
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.
❑ The installer has provided a copy of CF -6R (Installation Certificate.
❑ 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.
❑ 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
If fan flow is calculated"as 400cfm/ton 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=6% or less) ❑ ❑
Pass Fail
❑ THIERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑ ❑