0403-207 (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
��e! sionals Code, and my License is in full force and effect.:
License # Lic. Class Exp. Date
`�.��
pate -------,--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). '
O 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.
( A)' 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.
NATIONAL UNION 71653'3
(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,
Ishall not employ any person in any manner so as/6 become subject to the
workers'. compensation laws of California, -and agree that if I should become
subject to, the workers' compensation provisions bySection 3700 of the Labor
Code -I 6ll'fofrthwith comply withlthose'provlslonay��
Z
Date 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, damagesasprovided 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. li 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.
2 u
Signature (Owner/Agent), / '' Date
. BUILDING PERMIT PERMIT#
it/
DATEf" VAIN IATIf1N I OT (3r{OL'; .r� `i TRACT
1if 71C�i.Ir1 214
_002
JOB SITE
APN
ADDRESS A
US L ARE
8p�� CACTUS
7"270-02.7
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SHE A? KQ-U"PAILC
SkMALA QtTLOT'.AJZC
X312650 AV'2�[1.E 62
81260 �+,VxV-7r-- 62
LAQUINTA CA 92253
LAQLT.M A CA. 112253
(,7.1511)777-.6005 Cmit TBI
USE OF PERMIT ,
f 1 GLE F1111f LY DIA'a- MT
SPO a LOT 24, P1,.A N 4210B. -PERt'J1fT DOES NOT 111CLUDE POOL,
BOA, BLOCK WALLS OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION 1,355.00 Six
POACWP.A` TO 214.04 S.fi
GA.P.AC1EfC'.ARPORT 474,00 3V
TeAA C08T OF CONRIM rt:x ON
117,691 -.Icy
�'�{��'�^.�p'�_'p; �j Q' '7`�
iC H..%1SCWL XI{.fv ! {%Vd��.S.pE
CANS'1 RUCTIaN FEE 101-000-418-000 IM2.50
PLAN CHECK Ffvt 101-000-439-318 $51n.83
I'Jtt:CI1ANICAL EBF: 101.000-421.000 x.00
ELEC f PJCA.L F + L 101-000-:120-000 $f10.4I
PL.UMBINO FEE 101.00k)-419.000
STRONG MO )ON FEE, . RiSID 101-000-241-000 $11.77
ORQ1,90 FEE 101-000-42.'J-000 013100
DEiGELDPER IMPACT FEEL $2,4t)S.OG
l YMT r -TION AND MAN CHECK
$3,989.26
(� IESO 1'`1 PAH) FIRM
$0.00
MAR 0 4 2004 IPT FUS DUN NOW
CITY OF L.A QU!NTA /
FINANCE DEPT. t
RECEIPT
DATE
t.. �.
BY �Ll
DATE FINALED
INSPE O
INSPECTION RECORD
j OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
O
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
/p ig
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
(> o
Compressor
Insulation
ZoVents
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
PPROVALS
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
aste Lines
or
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
/ Q
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)
INSULATION CERTIFICATE
stallid in conformance with the current energy
This is to certify that insulation has been. in
regulation, California Administrative Code, Title 24, State of California, in the building located
81-845 SUN CACTUS LANE LOT 1024, 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
B TITLE: ACCOUNT REPRESENTIVE DATE:--,
Installation Certificate: Residential CF -611
Site Address PERMIT #
81-845 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 i 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
80%
4. COOLING INFORMATION
COOLING MANUFACT COMPRESSOR ACTUAL EFF: COOLING EQUIP COOLING
EQUIP. MAKE MODEL # SEER CAPACITY LOAD
A/C Lennox 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 provided for inspection.
Yes [� V�o ❑ N/A
6. SUBMITTED BY
PLy1.11' u44,, d DATE: O el
Signature HVAC Co4tract9'r ,