0402-210 (SFD)'�LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Cha er,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
t
Date �"" Signature of Contraeto,r,
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.
(P' 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 1Jt7 ON ' 7163033
(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' compensation' Section 3700 of the Labor
Code; -I -!hall forth pith&mpl,) with thtiose provisl � nns.
Date:. {.APplieant—_—/
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to.the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit . subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application find state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby -authorize'rrepresentatives of this City to enter upon
the above men Ion de pro perty� for inspection puYposgs. i}
-31 � ) 61"
Signature (Owner/Agent) A. Date
BUILDINQ PERMITPERMIT#
..DATE. -- -- VALUATION.- - .,. 'LOT' - - - Vy02�ii3.0 TRACT.. _ ---.•.._ -_
JOB SITE
ADDRESS
APN
81-881 SIt714 C-I.1-C..1"US LAM
764-2.70-017
OWNER
CONTRACTOR/DESIGNER/ENGINEER.
SHFA 1A QUW-fA UX
BIWA L& Qr.3d13 . k I—LC
i 1260 MENL E 62
8126-D AM;UFs 62
LAQITt�'l:.a�s. (',A. 922.3
LAQTJWfA CA .92253
(760)077-6005 Clete MD
USE OFPERMIT
VOLTALLSY bT T
O
'
313713 - IAT 21;l L", 4510A. PERMIT DOES 140T INCLUDE POOL, SPA,
BLOCK'W,1WSA DRIVEWAY APPROACH
C.uBTOi14 CONSTRUCTIOII 030,00 3F
POI:MPATIO 937.00 SP
GAR.A.C:PICARPORT 419.00 SF
ES1COW OF CCRMUCnOW
13 34WV7.50
CONSTRUCTION FEE 101-000-41$-000 $758, gp
PLAN CHECK AM 101-000-439-318 $617.6.1
MECHA 41C:AL FEE 101.000.421-000 "6e so
ELECTRICAL T:RICAL FEi~. 101-000•-420-000 $96.63
PLUMUM0 FEZ 101.000-419.000 1118,00
STR,O1401V1i11 IM4 F&S - RESID 101-000-241-000 $13.31
ORA,D1NC4 ME 101-000-424-000 S0.00
DEVELOPER IMPACT FEE $2,405.00
SIS-•l"OTAL CORTMUCM014 AND MAM CIP-M
10, 55
T WIS PRE -PAW iI',EE.'�
W -
D.- 11�
$0,00
p y
� JC7a7J F: ��.{' �f,'e9r'7 Dt°2:. S\4� 9tl
04 2004
E'M
CITY OF LA QUFNTA
FINANCE DEPT.
RECEIPT DATEe
BY
D NAL
INSPnC
�'
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
�y o• ��
Exhaust Fans
O.K to Wrap
_
F.A.U.
Framing
–d—
Compressor
Insulation
�� �� ni
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
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
jGas Piping
�p
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 PERMIT #
81-881 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
DISTRIBUTIONDUCT 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' A
80%
4. COOLING INFORMATION
COOLING MANUFACT COMPRESSOR ACTUAL EFF. COOLING ,EQUIP COOLING
EQUIP. MAKE MODEL # SEER CAPACITY LOAD
A/C Lennox 13ACC-048 12
x 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 ,�j
Ati �, xd ` o '(L G �2 DATE: -KI llello
Signature Installing HVAC Contractor
n
y 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
81-881 SUN CACTUS LANE LOT 1021, LA QUINTA CA
CEILINGS:
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
v
BY: . TITLE: ACCOUNT REPRESENTIVE DATE: O�