0100-212 (RPL)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.
6'51503 B C27 :X7131/2(
Date Signature of Contractor r' {
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 structun 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 Sianature 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 Policy No.
,O-0�:1'3`1'�0.1Yy, ANDS -6047
(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 sous 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 37.,00 of the Labor
Code;,I'shall forthwith comply with those'provisions. F "'
Date: Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an. employer to criminal penalties and civil fines up to $10 ,
addition to the cost of compensation, damages as provided for in Secti 6
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building an J a et
for a :permit subject to the conditions and restrictions set forth hi
application.
1. Each person upon whose behalf this application is made & each p rson
whose request and for whose benefit work is performed under or pu uant t
any permit issued as a result of this applicaton agrees to, & shall, i emnify
& hold harmless the City of La Quinta, its officers, agents and em
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)-,,2 W Date '
BUILDING PERMIT PERMIT# '
1
DATE VALUATION LOT 0100-212 TRACT i� .
fl p1
ry ry�
L'.i i " f i� � �;'•o�,..r.." �A.:�.!{9CK�aVSSA C�
J06 SITE ''
APN
ADDRESS
1- It,ITRO !1"
OWNER
CONTRACTOR/DESIGNER/ENGINEER
-
- _ - ._ — T ,-
af<`OLL YRl)1MRS IN'C'
lal MM,7 X11 us comm��icni ox
'74-n- 3 s1OVELY 1ANEM- SC.TI'YE242.0
41 W YUCCALANE
PAY DERM1 C,A 92260
BE04MA DU14ES s C A 92201
(760)3M-1400 CI31q 30"46
USE OF PERMIT
POOL A1dWOR i; A
POO;.,WA OSdZ„`,i''aM-ARAB I,A3tMERS 5: J. M IN P£.AM4 AT
PRE -MAST RR HOSPOCTION, POE'- EQU'tP.MT ZXC1.OSLtRR 12 NOT
1'13OLfTf��'.131Ii 'l'k4eS1 lP�'§?@�ti. -
POOL ANIDIOR 19FPA g!i,00aw I's
}WIT1➢ ,TW COSTOV C00MUMOX
pM^
A wr FER SU.1.4���j `4 K�l�MT A.
PLAN CR,ECK ARX 101--000>439.311; f 101,:M
CON:ai`It UCTiiON PEZ 101-000-418-000 $36Z06
MMI-TA,T ICAL MR -• POOL 101.00q-421= 000 $340
X'iLEC RIC:AiL YZE ..1 007 101-000-420-000 $45.00
PUIMSINt3MV •- POOL, 101.000.419.000 327.0
UU O
APA 2 2001
CONSTRUCTION' �,�4I51.t1..M�"Tti�tIC
X3653_2 0
CITY OF LA OUINTA
FINANCE DEPT IMS ]ME -PIMP
ftoo
Y0TALFP1TMrFLT8 DUE NOW
RECEIPT
DATE/ j
BY
DATE FINALED
INSPECTOR
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
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
Set Backs
steel
Electric Bond
POOLS - SPAS
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
Sewer Connection
Gas Piping
Pool Cover
Encapsulation
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:
May 27 09 09:27a
�- Ca10ERTS
p.2
Page 1 of 2
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (Page i of 8) CF -411
81-700 Tiburon Dr. - La Quinta, CA 92253 Precision Heating & Air Conditioning [ 818759
Project Address Contractor Name / License No,
09-505
Contractor Contact Telephone Permit Number
Pal -i l Van Vlymen 760-777-1724. 126977.
H[R Rater Telephone Sample Group Number
L , Sv( laay 22, 2009 "CC14-1798467559
Certifying Signature Date Certificate Number
Firm: Air Experts Air Conditioning HERS Provider:Ca10ERTS, Inc.
Street Address: PO Box 94. City/State/Zip: La Qulnta / CA / 92247
Copies to: Homeowner, HERS Provider and Building Department
This CF -41R has been registered with the CaICERTSe registry in accordance with the Title 24 & Title 20 of the CCR.
CaICERTSO Is an approved HERS provider by the California Energy Commission.
HERS RATER COMPLIANCE STATEMENT
The house was R 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 house Identified on this form complies with the
diagnostic tested compliance requirements as checked on this form. The HERS rater.must check and verify that the new distribution
system Is fully ducted and correct tape is used before a CF -4R may be released on every tested building. The HERS rater must not
fEEEMMMNE
until.a properly completed and signed CF -611 has,been receivedfor the sample and tested buildings.
has provided a copy of the CF -6R (Installatlon Certificate).tion system Is fully ducted (I.e., does not use building cavities awhere cloth backed, rubber adhesive duct tape Is installed, maer adhesive duct to a to seal leaks at duct connections.
D�A�QTS GYCVTG' cnn nuPr i CAsrAG`C ocnr lCTT(1N CAMIDI Te NCF CRFDIT!
NEW CONSTRUCTION
Duct Pressurization Test Results (CFM @ 25 Pa)
Measured
values.
1E
Le li:eekageN/A
2
Fan Flow: Calculated (Nominal Cooling '-_.' Heating) or-.-.-* Measured
Enter Total Fan Flow in CFM:
1600
3
N/A
N/A
ALTERATIONS: Duct System and/or. HVAC Equipment Change -Out
4 Enter Tested Leakage Flow in CFM from, CF -6R: Pre -Test of Existing Duct System Prior to Duct
System Alteration and/or Equipment Change -Out.
5 Enter Tested Leakage Flow In CFM: Final Test of New Duct System or Altered Duct System for
Duct System Alteration and/or Equipment Change -Out.
171
6 Enter Reduction in Leakage for Altered Duct System
[Line 4 - Line S] - (Only if Applicable)
7 Enter Tested Leakage Flow in CFM to Outside (Only if Applicable)
8 Entire New Duct System - Pass If Leakage Percentage < 6% [ 100 x ( Line 5 / Line 2 )]:
❑ Pass ❑ Fail
TEST OR VERIFICATION STANDARDS: For Altered Duct System and/or HVAC
Equipment Change -Out, use one of the following four Test or Verification
Standards for compliance:
9
Pass If Leakage Percentage < 15% [ 1D0 x ( Line 5 / Line 2 )]: 10.69%
R Pass ❑ Fail.
10
Pass if Leakage to Outside Percentage <= 10% [ 100 x ( Line 7 / Line 2 )J:
❑ Pass ❑ Fall
11
Pass if Leakage Reduction Percentage >= 600/b [ 100 x ( Line 6 / Line 4 )]
and Verification by Smoke Test and Visual Inspection
❑ Pas ❑ Fail
12
Pass if Seating of all Accessible Leaks and Verification by Smoke Test and Visual Inspection
0 Pass ❑Fail
Pass If One of Lines #9 through #12 pass
Pass ❑ Fa11
https://www.calcerts.com/certificate_print.cfm?lots=0,12697?&UseCF4R=1 &cert_type_id... 5/26/2009
MAY 26,2009 09:14A page 2
May 27 09 09:28a -
Ca10ERTS r Page 2 of 2
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING Page 3-4 of 8) CF-411
81-700 Tiburon Dr. - La Quinta, CA 92253 Precision Heating &.Air Conditioning / 818759
` Project Address Contractor Name / License No. p
09-505
Contractor Contact Telephone Permit Number
P Van Vlymen 760-777=1724 126977
ITERS Rater Telephone Sample Group Number
V Clay 22, 2009 CC14-1798467559
Ce7r-tilVing signature Date Certificate Number
Firm: Air Experts Air Conditioning HERS Provider:CaICERTS, Inc.
Street Address: PO Box 94 City/State/Zip: La Quinta / CA / 92247
Copies to: Homeowner, HERS Provider and Building Department
This CF-4R has been registered with the CaICERTSO registry in accordance with the Title 24 & Title 20 of the CCR.
CaICERTS@ is an approved HERS provider by the California Energy Commission.
HERS RATER COMPLIANCE STATEMENT ,r
The house was R Tested DApproved as part of sample testing, but was not tested.;
As the HERS rater providing diagnostic testing and field verification, I certify that the house Identified on this form complies with the
dia nostic tested compliance requirements as checked on this form.
The installer has provided a copy of the CF-611 Installation Certificate).
HERMOSTATIC EXPANSION VALVE TXV
Access is provided for inspection. The procedure shall consist of visual verification that the TXV is installed
on the system and installation of the specific equipment shall be verified. '
HVAC System TXV1 Pass ❑ Fail
r
https://www.calcerts.comkertificate_Print.cfm?lots=0,126977&UseCF4R=1&cert typ& id... 5/26/2009
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MAY 26,2oo9 o9:14A' page 3