0402-204 (SFD)1 LICENSED CONTRACTOR DECLARATION
._il,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
Prroofossionals Code, and my License is in full force and effect.
License # Lic. Class rr Exp. Date
B 6/30/05
Date nature nature of ContractorF ��'"
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 I Policy No.
NATIONAL W41014 7143833
(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' compensat�n-provisions of,S ction.3.7,0, of the Labor
Code,Tsfiall forthwith comply with those provisions. ff`
Date:
-� 1 '1 f, I Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application anAtate that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon '
the above-mentioned propertyfor inspection purposes.
31.2 . . V.
Signature (Owner/Agent)_. J �--��`°' Date tjf
': BUILDING PERMIT PERMIT.#a�P
nATF VAI I IATIr1A1 I r)T4 LdS a'�i, .:-�. TRAr;T
'143,180.40 101 301023
JOB SITE
ADDRESS
APN
1.-802 :SUPT CACTUS LANE
7614--270-01 7
OWNER
CONTRACTOR / DESIGNER / EN (NEER
8111KAL CzU"fKUC
HIM tAQMMUC
81260 AVEMM, 62
91260 AV" a ^ 62.
1: A QUINTA CA. 92,253
LA Q'UINTA CA..9225 3
(760)777-6005 M.O. TIM
USE OF PERMIT
MG1YP.F I tiDJii1.7IvCf
Sn-1 < LOT 101; PL.taN 43208. P R14UT DOES NOT 114CLUDL POOL,
SPA, I31.C?t;KWARIAZC}It,13112.1VEJN.4V APi5I2O.ACH
CUSTOM CONSTRUCTION 1,088.00 OF
PORCHIPA,T1O 17'7.00 SW
dArct Gi(C.ARPORT 43$.00 SF
FMMATED C09r 011 CONSTRUMCAN
143,180ar11
PERMT EV ESUiVMIARY
CONSTRUCTION FEE 101-000-418.000 x°"150
PI AIR CHECK M '1101-000-439-319 $641.18
MECHANICAL FEE 101.000«121.000 M130
ELECTRICAL IYU 101-000.420-000 $102.24
MIMING YEZ 1011.000.415.000. $122,73
ST:.t7NC9 MOT104, IEE , RESIiD 101-000-241-000 $14.32
GRADING FEF' , 101 -000--4.23.000 $13.00
DEVELOPER YMPACT F22 $2,405.00
SUB TOTAL C'OMMIC1:LCM AM PLAN CHECK
$4,168.2.9
r� 9� LESS PRE -P A,i17 ;1` ' S
W.00
MAR 0 4 2004
CITY OF LA EPt, NTA
EINA�ICE DEPT.
RECEIPT
DATE /
BY
DATE FI LED
INSPECT R, /
•^ f
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
_ (f �'
3
Ducts
Return Air
Steel
Combustion Air
Roof Deck
6'
Exhaust Fans
O.K. to Wrap
_ �1,
F.A.U.
Framing
Insulation
iii Y
/ -�!�
Compressor
Vents
Fireplace P.L.
/
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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 Top Out
Shower Pans
_ _
3 ��-�
U%
Plumbing Final
Equipment Enclosure
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 D
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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 located
81 -802 SUN CACTUS LANE LOT 1101, 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
A
BY. .41 �11 TI
A 111"i. TLE: ACCOUNT REPRESENTIVE DATE:
Installation Certificate: Residential CF -6R
Site Address PERMIT #
81-802 Sun Cactus Lane
1. BUILDER INFORMATION SUBDIVISION: Trilogy @ La Quinta
Shea Homes - Trilogy - LaQuinta CITY: La Quinta
81260 Ave. 62 COUNTY: Riverside
La Quinta, CA 92253
INSTALLING CONTRACTOR: WEST PAC AIR CONDITIONING
2. PROJECT INFORMATION
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 G40UH48B-090X 80% 88000
Qn 0/-
4.
i
4. COOLING INFORMATION
COOLING . "MANUFACT
EQUIP. MAKE
A/C Lennox
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.
6.THERMOSTATIC EXPANSION VALVE (TXV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is pr vided for inspection.
Yes No 0 N/A ❑
6. SUBMITTED BY
DATE:
Signature Installing HVAC Contr o