0402-200 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby.affirm under penalty of perjury that I am licensed under provisions of
l.Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Trofessionals Code, and my License is in full force and effeci. n
License i p Lic. Class exp. Date
Date-- ' ( St nature of Contractdr.•�
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.0 ,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.
0°) 1 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.
14AT101MI, UNION 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 agrep,.that if I should become
subject t4 the, workers' compensat9nfprovisions,of',Section 3700 of the Labor
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,1he 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 Mate laws relating to the building
construction, and hereby authorize representatives of this City to. enter upon
the above-mentioned property for inspection J urposes. b�
/ ""gym
Signature (Owner/Agent)`• Date ���'
BUILDING PERMIT PERMIT#
nATF VAI I IATION I nT ()WJ02..2Q 1 TRGr.T
U49M.140 z7 30023
JOB SITE
APN
ADDRESS
=
_8W ffulq CAC.rus L AfflIr
764-270-011
OWNER
CONTRACTOR /DESIGNER / EN INEER
SIMM LA
81 -MA LA QTJD:rfALLC
91260 A T-KNL JE 62
812£60 AV +WIA S 6.2
LA QUIMA CA 92253
1A QtTJN..t'A CA 92253
(7taOr,77.6005 SAIAO TBD
USE OF PERMIT
GLLe rAWLY DXAW .119,'
SEPD , LOT 77, PLAN 4530A k'uTt.I T DOES 'NOT INCLUDE }BOOL,
SPP BLOCK WA LIX OR DRNICWAY APPROACH
CUSTOM CONSTRUCTION. . 1,736.00 SI`
POItCH/NA.'T.IO 1:34.0 SP
C1.ARQ OWC:A)I` PORT 5"13100 SF
TEYi7'!! ATk,'D G lff UP MN5b`.1 M C! ON
149XV3.40
MIUMf 1.� ��; gubilwRy
CONSTRUCTION FEE 101.000-418.0100 $814.50
PLAN CHECK #EEv 101.0001 439-318 $6513.04
Bvil'CH NICAIL FEE 101-000-421.000 $53.50
E1.EC'T,Ir.ICAL KEE 101-000-420-000 $106.42
P'LUM131110 FEE, 101-000-419-000 8116.7:11
STIF.ONO NIOTIO14 FIE « MID 101 -00x7 -241-1",x00 $14.98
t3lUDIWO .FEE 101.000--423-000 $.M00
D_FVXWPIr,(I2 IN'IP.AC.:T ME $2,4ttnao
-- _ ZM#T0TAL-CQ1 .37TUTCUTOX.tlM P1.JW C1r�..C.I;;.
$4,180.19
IR
O ML P1<131iM FUS DUX ROW
�pA • � 0 1
$4,160.19
CITY,,:, — wo:41A
FINANCE DEPT.
RECEIPT
DATE !{ // �,,_
BY/
DATE F NA✓L
INSPE O
INSPECTION RECORD
M
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs_
Underground Ducts
Forms & Footings
ct
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
p
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
OF
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_QG
Encapsulation
Gas Piping
Gas Test
L Q
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures 42
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
.:..... ..,. ..:...�..y ........ .:. �. ._..:......e....,^.r..r...-........r./r„r.e.,e..�e�/c.rtrwe... .... .. .�.r,.v. r.Q,a✓c...... .r.. ....... ,....ac .. .. ,..'. '... [ .. .. .. .. .. .. .:�. ..
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title24, State of California, in the building located
81-809 SUN CACTUS LANE LOT 1027, LA QUINTA CA
CEILINGS:
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
WALLS:
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-13
GENERAL CONTRACTOR: SHEA HOMES LICENSE #
BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517
BY: TITLE: ACCOUNT REPRESENTIVE DATE:
. .. ....-�..:�•: .. ...:...:..'.:�:-,.;:..,..:v '• .... ..r.. .. ... .:... ..•.y.,yl;+.:.rr:%%li�v. .. s.: J:'J.......>J. ?...�..../Y.1.-. ..7' 4./....r. ...c. .. .. ...,. ...:. .. ...
Installation Certificate: Residential CF -6R
Site Address PERMIT #
8.1-809 Sun Cactus Lane
1. BUILDER INFORMATION
Shea Homes - Trilogy - LaQuinta
81260 Ave. 62
La Quinta, CA 92253
INSTALLING CONTRACTOR:
2. PROJECT INFORMATION
SUBDIVISION: Trilogy @ La Quinta
CITY: La Quinta .
COUNTY: Riverside
WEST PAC AIR CONDITIONING
DISTRIBUTION DUCT OR PIPING R -
TYPE VALUE
Flexible Ductwork Flexible Ductwork
in Attic and Will have a R -Value
Between Floors. of 4.2 or Better
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 80UHG4/5X-100 80% 100000
80%
4. COOLING INFORMATION
COOLING MANUFACT COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
EQUIP. MAKE MODEL # SEER CAPACITY LOAD
A/C Lennox 13ACC-060 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.
6.THERMOSTATIC EXPANSION VALVE (TYV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is provided for inspection.
Yes FNo ❑ N/A ❑'
6. SUBMITTED BY
DATE: ",
Signature Installing HVAC Contractor