0307-366 (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.
Licensf # Lic. Class Exp. Date
0160335 FA 03/31/2(
Date �?` / ,� Signature of Contractor /�
C_/
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 STATR,1jU1gD Policy No. ifi0�3@1.012
(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 �fo with comply with thosg provisions.
Date: Applicant t /
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 employeps—
2. Any permit issued as a result of this application becomes null and vo dile
ce
work is not commenced within 180 days from date of issuanof siehll`
permit, or cessation of work for 180 days will subject permit to cancellatrtI"r
I certify that I have read this application and state that the above informatio
• correct. I agree to comply with all City, and State laws relating to the build g
construction, and hereby authorize representatives of this City to enter up n'
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �'= Date 1% tis it fav
BUILDING PERMIT PERMIT#
0"7-3CZ le
DATE VALUATION LOT TRACT .
$21.4,107.30 2£I 29147.2
/1 .� �-f . ,� a
JOB SITE '
ADDRESS 81„.11/5 �bMMK.EC()C:K =J's
APN
1tit�.^3'',10" 17
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CR'V G oLk"Vis�.'1'i'
AJ%MR0 JY INEVEWP3uOW COWANY
5140 AVMA EtsTC3NA3
5140AVRUDAFNCD4A3
CA BAD CA 92008
CAIU. .BAD CA 92008
(760)804"6868 03V. 337E
USE OF PERMIT
SCyLE FAN.ETLY DSV tI
SFD - LOT 38, PL.kN I.A. PFRMfT Z7C,oF.S'NOT IAZCLUOE SLOCK'WATXS, -
POOL, SPA OR. 9.7IUVEWAY APPROACH
CUSTOM CONSTRUCTION 3,503.00 SF
PORCWP.A,TIO 558,00 SF
GAR.AiIMARFORT 605,00 BF
ES �A ED COST OF C:C3NMWUCTITO Y
214,1017.30
CONSTRUCTION 53,04100
PLAN CHECK FEE 101-000-439..318
MECHANICAL, FEE 101-000»4.21.000 X111.00 .
ELECTPUCAL FM 101-000-4120-000 $133..14
PLLFMj3j'IdO FXE 101.000.419.000 $197.,75
311RON G MOTION ME fI931T) 101-000-241-000 (321,41
GRADING FE 101-000-023.000 t15,�0
:DWELOPER litslI)ACT ME
ART IN PUBLIC PIACES - fiESIE 770.000.41,45.000 $35.27
:QUA -TOTAL, C':')MMUf�7'�ON fid D PLAN CMCK
3 PRE PAID F
$13,00
DUE
.-1 NOW
TaaTAL I EF.Wr 17019
14 2203
OF T
DATE��•+
BY J j
DATE FI LED
INSPE TO
J
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
F.A.U.
Framing
b�
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
/
II -I th
_
%- 6
Final
Final
BLOCKWALL A PROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
3-
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
/ v -A
Encapsulation
Gas Piping
ja
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:
WT 0,18�o� ups
05. 90�.� Dema
�� —m 0—_ Aoft...
PO. Box 621
Rancho Mirage, CA 92270
Email: OESNRG QAOL.COM
ell- CA0EC
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
Date
. ASHBROOK COMMUNITIES
Project Title
P.G.A. WEST LA QUINTA
Project Address
STEVE VAN LUE II
Builder Contact
RICHARD KROWN
HERS Ratey) ,
3292
Certifying Signature
Firm: DESERT ENERGY SERVICES
Street Address: P.O.. BOX 621
Copies to: Builder, HERS Provider
CF -4R
Builder Name
760-801-3981 _ PLAN 1 2 UNITS
Telephone I n Number,
760-250-1852 GROUP 4
Telephone Sample Group Number
JUL Z YUUb LOT 28. 1 OF 2
Date Sample Lot Number
HERS Provider: CHEERS
City/State/Zip: RANCHO MIRAGE, CA. 92270
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 100
If fan flow.is calculated as 400cfmlton x number of tons enter calcuated
calcul here 2000
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) = 5
Check Box for Pass or Fail (Pass=6% or less)
Pass Fail
J
® THERMOSTATIC EXPANSION VALVE (TXV)
r Thermo static"Expansion Valve is installed and Access is ® ❑
® Yes N0 provided for inspection