0402-209 (SFD)LICENSED CONTRACTOR DECLARATION
I,herAy-affirm under penalty of perjury that I am licensed under provisions of
1Ch9pfer 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
i'l,
DateJ Sianature 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 &, Prof essionals 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 Policy No.
NATl0NAL UNION 7163337,
(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 sofas to become subject to the
workers' compensation laws of California, and agree that if I should become
subject,to the workers' compenVtion provisions of Section 3700 of the Labor
Code�jsha� l forthwith comply Ith,those proGi rions
Date t� Applicani••-f/ 1
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section. 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application:
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter'upon
the above-mentioned property -for Inspe tion purposes.��
Signature (Owner/Agent)- Date
BUILDING PERMIT PERMIT#
nATF ` VAI IIATION IOT ()4W. 0P TRAr:T
r
22 3f1C123
JOB SITE
ADDRESS
APN
8.1-869 sUi`1 CA(,vrUS'LAM''
7&$-2704H7 r
OWNER
CONTRACTOR/DESIGNER/EN INEER
SMA 1A QUI I T,k 1JC
ffHEA LA X71' ix%37"A LLC
81260 AVIE�WIJF t52
81'260 AN'Ze W, 02
LkOjMIT.A. CA 92253
LA QUWrA- Ck 1.2253
(760)777-6008 C IAt TBD
USE OF PERMIT
S.CATTaOU S-AMMY DWELLN '1
SVD • I.t: r 22, PI -M 45200. PM1411T DO&S NOT 19CLUDE P001, ,
EPA BLOCK, littALLS OR DRIVEWAY APPROACH
CUSTOM CO NSTRUCTI(M 11=00 Sly
FERCF13i.Pio • 76500 Ss
0-AV3CMWAY7ORr V 1
.Wa—MIA7FD ('OST ad.•' CNl.Lre7 X34JCTION
144, ,%4.50
PERMIT VVC WAGAAR 1'
C'ONSTRUC."TION ,SEE 101.000.418.000.
PIAN GliEICKFEE$644.00
1JiECILA.141MLFU 101.0001.421.•00,,0- " $7130
ELW,TRiCAL FEE 101-.000-420-000 $102.34
PLU'A9MO FRE 101.000.419-000 $122.79
ST RONO 'NIOTIMI nL-11'JE41D 1011-000-241-000 $11.46
GRADING FEE 101.000.423.000 $15.04
DKVYLOPER IMPACTFEE $2,405.00
USS PRE -PAM TWO
$0.00
A,i., P '' ' —ff FEES DUE NOW
72V5
MAR 0 4 2004
CITY OF LA QU!NTA
FINANCE DEPT.
RECEIPT DATE /
BY
DATE FI LED
INSP T R
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 Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
d
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines _
Water Piping ��
Heater Final
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
Fbdures
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 PERMIT #
81-869 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 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 (TYV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is provided for inspection.
,Yes W No ❑ N/AEl
6. SUBMITTED BY
DATE:
SiE"stl ling HVAC Contractor,
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INSULATION, CERTIFICATE
f
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
J
81-869 SUN CACTUS LANE LOT,1022, LA QUINTA CA
CEILINGS:
R
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
WALLS:
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TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS:. R-13
GENERAL CONTRACTOR: SHEA HOMES LICENSE #
BY: TITLE:.
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE #-221517
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BY: TITLE: ACCOUNT REPRESENTIVE DATE:
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