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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
.a 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
\ 7�/t7.af3S B f� OV3112C
Date l tJ//'3 Signature of ContractorJ/
-.+" ' !'(
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 insurance carrier & policy no. are:
Carrier STATE MID 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 thos provisions.
mate: 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 ! t/l j a�
Y_
BUILDING PERMIT PERMIT#
r
-•3C
DATE VALUATION LOT TRACT
29147.2
JOB SITE
ADDRESS 8140 SUMMICOM IULLS
APN
762 -350 -MID
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CPIV GOLF AIM.
-A:�`FMROO.K.1W-M�'.�.{yrIMEWT COMPANY
5140,PlMM:E.DAUT.C`.WAS
51140AMINMfl, ON
Cox SB.A D CA 92008
C. ARUSBAD CA 92008
(760)804.6868 117M €# 3376
USE OF PERMIT
S't. '7CiU RA LY L'tVM-U 3kIG
SM - LAR' 31, -PLAPt 3A. rRZ-PM1T DORS NOT INCL OS k'tLOCK 'BALL.%
P00I4 SPA OR F31d.ItIKWAY.APPROACH. In%REDUCT1'C3k1 TO PLAN CHECK
FEE DUE TO MULTIPLE ISSUANCE 0? SADAZ PIAN TYPE
CUSTOM COHSTRUC' IMI 2301100 By
PORC H/PA' O 5 V.00 33F
GAP AGEXARPOKIT X00 8F
Y:'MMA= COST OF CONSIR'�,�MO,N
2369$77M
9$77M
POMOT I, W. SUIMA RY
CON51'11tiCTIDN FES: 101 X000-410 000 &1„ 119100
PLAN CHWX FEE ox
MECHM11CA L. FEE 1014000.421.000 WA
FLECTWCAL NEE 101-.000420-000
PLUA48I4 O FEE 1014000-419.000 $130, s0
Si'RONO MOTION 1 - PYSID 101.000-241-000 $.23.64
0PA,i'iING i 91 101-000.423.000 RI$,Q0 ,
OVELOPER..IMP.ACT RX,$2;�05.itt!
AR,T IN PUBLIC PLACES • %ASIC 2,70y000-443.000 190.94 '
isONM:i1'i3YK)9AND PLAN C,HECT.
1 (�1. 311ITY*,P VE30
sofa
$0.11"
j OTAE. VERMU FEES DURPOW
-
NOV 14 2003 `
CITY OF LE; QUIJ47:A
FINANCE DEPT
RECEIPT
DATE
2v
BY
1vw
DAT€�I LED✓
! 34E
INSPEC
�O L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
t. BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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 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
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
6hapte,& 9 (commencing with Section 7000) of Division 3 of the Business and
" Professionals Code, and my License is in full force and effect.
Licensb # . Lic. Class Exp. Date
760335 B
Date Signature of Contractor
OWNER -BUILDER DECLARATION
038112C
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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, contractingl5with licensed
contractors to construct the project (Sec. 7044, Business & ,P(ofessionals
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:
Carver STATttIi11I� Policy No. 160"01.011
(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 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, indemnity
& 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
BUILDING PERMIT. PERMIT
DATE VALUATION LOT TRACT
11/14/,200 29147-2
JOB SITE
APN
ADDRESS f391-�i1:5 a 1 1`I1!d 'C:'OCX HU;LS
-ow
OWNER
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CRV C1C>l:Y iii?=
A BBROOK 13EVEX)PUE T COWA i Y
5140 A IDAW. CINAS
5140A'V041DAYTC]NAS
CART -BAD Cg's 92008
CARLSBAD CA 92006
(760)804-6868 C)", 3376
USE OF PERMIT
i
VD - LOT 31, PLAN 3A. PERMIT DOES NOT fOCLUI?L BLOCK WALLS,
POO,14 8PA.OR LjF.WZWA f APPROACH.7W REDUCTION TO PLAN CHECK
FEE DUE TO MULT'IPLZ ISSUANCE OF SAME PLAN TYPE
CUSTOM CONSTRUCTION 2,001.00 Sl:
P RCHIPATIO '37i'.Ot1 SF
OARAOEtC.Et.i PORT 536.00 JP
.ESTTMI.MD cosr OF CON vt"MIJLMON
7_361 377450
CONSTRUCTION FIR 101-000-4118-000 31,119.00
PLAN CHECK FEL 101-000-439-316
MECHANICALFEE 101-01004.21.000 103.90
ELECTRICAL, F '10'.1 -Cil 0-420-000 j; t 61.16
PLUMBIW, FRX 101 "000.419.0( t) $180.30
STRONG M011ON FEE: • MID 101-000-241-000 $23.0,4
aPAD roo nis 101.000.42:1.000 S�1S.00
DEntrELOPFIR IMPACT PER $3, 511.00
ART IN PUBLIC. PLAC�� a ki TE 2719.000.445.000 $90.94
SUB -TOTAL C0)+`3M(1'C7J01d AND PLAN CIBC%
$4,307.57
LF SS PRE-PPJD FFES
$0,00
TAL p?9I 31!I�'T 9i XWS 33TTE .NOW
$4X7.57
RECEIPT
DATE
BY
D E FMhALZE
INSPE T
3a
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
Compressor
Insulation
a
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
DrMqll - 15t. th
Final
Final 3d
BLOCKWALL A O PROVALS
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
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
02 2F
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Lor
EDIERGY
AHI NEc�C1{ ]}�L
P0. Box 821
Rancho Mirage, CA 92270
Email: DESNRG MAOL.COM
CAOEC
Ph/Fax(760)564-2044
Cell: (7601250-1852
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
RICHARD KROWN
Builder Name
760-801-3981 PLAN 3 2 UNITS
Telephone Plan Number
760-250-1852 GROUP 4
HERS Rate Telephone Sample Group Number
#CCNRK613292 JUt 712004 LOT 31
Certifying Signature Date Sample Lot Number
Firm: DESERT ENERGY SERVICES HERS Provider: CHEERS
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
CF -4R
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
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑ ❑
r-
SPECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211 '
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED_ MASONRY ❑ FIRE PROOFING
❑
O iER 0
/
JOB LOCATION �J ] ` � O�
�, l �V
REPORT SEQUENCE N0.
TV 'UCT -r /
LW
� �
PERMIT NO.
GATE of -
DAV Of WEEK
MATERIAL DESCRIPTION
ARCHITECT _
INSP CTO
HRS. CHARGED
O�/
ENGINEER
Wl
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL �^ SUB
- CONTRACTOR ._ 6( z+ C L _ CONTRACTOR __u
( I -MAA-IA-d Ljla
COPY SENT TO CLIENT O
CO TINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
i HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
'3V SIGN LRE OF REG ISTERE 113N SPECTOR
So�61��
DATE OF REPORT REGISTER NUMBER
It