0402-096 (BLCK)LICENSED CONTRACTOR DECLARATION
I fiereby 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
630934
Date,"- # s �_ 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).
( ) 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:
Cartier Policy No.
ALVIONAL UNKM FT 7165833
(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 tolthe workers' compensation.provisions.of.Section 3700 of the Labor
Code,el-shall forthwith complywith those provisions...
Date: 1l 4` Z
aApplicant
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
C
BUILDING PERMIT PERMIT #
DATE VALUATION LOT '- a >� TRACT
JOB SITE
ADDRESS
APN
8.1-749 .4,VJJK CAMUS LANE
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SIMAHCWM
SMA :� o S
81 -260 AVENI31? 62
w 1-260 MYMNI 62
1,A QU.WhA CA 92883
LK Qt WrA CA 92883
(909)833-8996 CEIL# 6876
USE OF PERMIT
137'L . 6' OPR DAN IffAL!, 53 I. F. HOTH
b M WAL1, 137,00 LF
4 V11. WALL 5300 LF
COST OF CCJ.I+T�'�`RUC'�34�W
4.00
MOW{5� y�� y�e ` d ,� g�{,�'rpES.l7i'JlAT'.1;D
�A:r�Y,iY3Nri4 �.Q.�- �7vVJ.iY.iiYA,d9.�9+7C
CONS TRUCTlM FEE 101-000-418-000. 472,60
EEE_ 2904
SM -T O`1'AL C'd?3.' STRUC f1OR Al.�1YL PLt+tRi, 4
V 72.C5e0
�Ct�l;lyi�rt�°yftCy: ryd7��j�
.4i3.�.3.1 ,C'J[OdS�"'&-fi7�Rd:.' .Z'.4 F.;,'
. i .00
TOTAL rLMOT PMES DUB, NOW
$72.00
RECEIPT
DATE
BY1_
DF F F�,
INSPE
4
.<.
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set BacksElectric
Footings 3/ZG p
Bond
Main Drain
Bond Beam 1p
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
COMMENTS:
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)
Installation Certificate: Residential CF -6R
Site Address
81749 Sun Cactus Lane
1. BUILDER INFORMATION
Shea Homes - Trilogy - LaQuinta
60311 Trilogy Pkwy
La Quinta, CA 92253-7642.
INSTALLING CONTRACTOR:
2. PROJECT INFORMATION
DISTRIBUTION
TYPE
Flexible Ductwork
in Attic and
Between Floors
DUCT OR PIPING R -
VALUE
Flexible Ductwork
Will have a R -Value
of 4.2 or Better
PERMIT #
SUBDIVISION: Trilogy (ti) La Quinta
CITY: La Quinta
COUNTY: Riverside
WEST PAC AIR CONDITIONING
I, the undersigned, verify that the equipment listed in the category above my signature is the actual equipment
installed and that the equipment meets or exceeds the requirements of the Appliance, Efficiency Standards. In
addition, Ihave verified that the equipment is equivalent to or more efficient than the equipment specified on the
Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards for
residential buildings.
3. HEATING INFORMATION
HEATING MANUFACT HEATING UNIT. ACTUAL EFF. HEATING EQUIP HEATING
EQUIP. MAKE MODEL # AFUE CAPACITY LOAD
Furnace ~ Lennox
4. COOLING INFORMATION
COOLING
MANUFACT
EQUIP.
MAKE
A/C
Lennox'
G40UH48B-090X 80% 88000
80%
COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
MODEL # SEER CAPACITY LOAD
13ACC-048 12
The building design heat loss and design heat gain rate have been determined using a method specified in Section
150(h) of the Energy Efficiency Standards, and are two of the criteria used for equipment sizing and selection.
&THERMOSTATIC EXPANSION VALVE (TXV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is provided for inspection.
Yes ❑ No ❑ N/A ❑
6. SUBMITTED BY
`SoSC fMnC Sr'o /9 1,4 DATE:
Signature Installing HVAC Contractor
07/08/2004 09:31 17607769980 HOLLY PAGE 05
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INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building at
4�. 81.749 SUN CACTUS LANE LOT 1032, LA QUINTA, CA
CEI INGS:
TYPE: BLOW MANUFACTURER: Certainteed THICKNESS: R-38
WALLS:
TYPE: BLOW MANUFACTURER: Certainteed THICKNESS: R-13
GENERAL CONTRACTOR: SHEA HOMES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE #.221517
BY: u4ftk d629 -TITLE: ACCOUNT REPRESENTIVE DATE: `f