0304-315 (SFD)• LICENSED CONTRACTOR DECLARATION
VA Thereby affirm under penalty of perjury that I am licensed under provisions of--
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CN W Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
LOLLI
7�rU9 5�:331f5S
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Z ir� Date";Signature of Contractor •' t
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•Z 1.—o1 OWNER -BUILDER DECLARATION
JUCID
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
W License Law for the following 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 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O N
O
d Z WORKER'S COMPENSATION DECLARATION
C:) Z I hereby affirm under penalty of perjury one of the following declarations:
r FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, 'as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q C) (!J I have and will maintain workers' compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. Myworkers' compensation insurance carrier & policy no. are:
� z Carrier OTATI ; 'UNP Policy No. 16033f.1.012
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those rowslons.
Date: 1,.- !% R"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
USaddition 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 applioaton 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)"" - F� Date t - '
PERMIT #'
BUILDING PERMIT alien � r
DATE VALUATION $214,W7,34 LOT TRACT
JOB SITE, ��S'COC ,s 1762-1w,021APN
ADDRESS M�I N'rf4y
OWNER
/ DESIGNER /
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Ck?i.IFes`.&'3±`Q C,.. 7CIO CA?7I.RF3AD CA 9200F,
. (760)i3';4-686-8 MIR, :11'476
USE OF PERMIT
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RECEIPT
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RECEIPT
bAT214T'191
BY
ATE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
D /P,3
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap 9
F.A.U.
Framing
7
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection$
Encapsulation
Gas:Piping .
Gas Test
Appliances .
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring_'
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power ✓
Final 7 tr. 144
Utility Notice (Perm)
COMMENTS:
�/2T/3
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�ADEC
ENERGY � --
.
RD. Box 621 Ph/Fax (7130) 5542044
Rancho Mirage. C+4 92270 CdA: 176 0) ZSD-1652
Email: Rl<rown62370aol.com
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page l of 7) CF -4R
Pffindf 96 Ph --3 11-gey-03
Firm: PJFA
Street Address: =17 • Bp)( (#I-1
Copies to: Builder, HEMS Provider
De
�shb�aolc � �rr,m(t,nl�,�s
Build re Na e
Ian Number
g:!;il C2vvp * ®�
Sample Group Number
$ 3A
Samp a House Number
HERS Provider. &A-1✓E-Q,.S.
City/Slate/Zip: 6,0-11D 11)x, C- E & • ZZI-0
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested -Approved as part of sample testing, but was not tested
As the HERS rater providing diapostic testing and field verification. I certify that the houses identified on this form complN.
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.platfotm returns in lieu of ducts)
❑ Where cloth backed, rubber adhesive duct tape is installed mastic and drawbands are used in combination with cloth
backed. robber 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=60A or less) ❑ ❑
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
Yes is a pass
❑ ❑
Pass Fail