0403-101 (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 arid'~'
-;7E,I:0fes�,iurlal5 Cude, wid my License Is In tUll TtlPCe And effect.
License # - Lic. Class �jA Exp. Date
2281
Date - �- 4'`Signature of Contracto
T
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 Policy No.
NATIONAL LTJ41ON "iI55$3 i
(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, andagreethat if I should become
subject to the workers' compensation, provisions of Section 3700 of the Labor
Code; l�shall#forthwith comply wifh'tthose provitg ons.
Date: -` +: `Applicant.( .'• `�' r "`" °°°"°'
I
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 thivapplication 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 i4e,
"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 propertyforinspection purposes.
Signature (Owner/Age )✓-s' -•-tea Date
BUILDING PERMIT PERMIT#
nATF vAi i IATinni L?T 0403-105 TRACT
U42,357M 20 30L►�:�
JOB SITE
APN
ADDRESS 'SIpf (,,ACT fTL tp
7&4.2744)17.
OWNER
CONTRACTOR/ / EN INFER
WEA. LA QUIN T'A U.C3
StraA I A eQUIN A. UC
81260 AVENUE 62
si 260 Affly-m P 62
is€Lf, UNT'A tom. 92253
LA CA 92253
0��ra- 005 C A TDD
USE OF PERMIT
SPID - WT XO PLAN 4,3160. P310AT iJOES 7,t0`l INCld):1f3b PDOI, SPA,
BLOCK WALLIS. OR .LJRiiiMAY APPROACH,
:
CUSTOWCO1vI TRUCTION 1,6:avo Sr.
PO;R,C13f1,AT10 319.00 Sr
s,' 9A11,&OFICAR.POnT 5510 OF
C'' NSTRIiCTJON FEE 101-000-418-000 S"MOO
PLAN CHWIX FEE 101-000-499-318 $6.",36
MECHANICAL FEE 101-000.421-000 $54150
BLECTW>'v'` LFEE 101-000-420-000 $101.90
PLi.)MBINO FEE 101.000.419.000 $140.73
STR.0Ni'1 A40TJ0.4 FF I;, FXLND 101-000-241-000 $14,.14
4311A1D1340 FEE i 03 -(illi?-423.000 $15.00
DF,VZIX)PER IMPACT FEE $2yQ03.01)
''.�--T'CYTAL CON67 0011100 ASS PI" CAE(Te,
$4,216.65
LUM ME -PAW Mr.3,
50100
C TA -1'a ?'Ef2,11 C1. n.S DVEI NOW
U:
$d4� E F,o,1 jai
MAR 2 4 2004.
Clic( OF I -A QWNTA
ECEIPT -.
j
�f. r. /
BY
h,/
E INA
Z.
INSP
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
6
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Z 'D y 6'!sf
Compressor
Insulation(1;K
Fireplace P.L.
l
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
zy
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 Pibg. 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
Gas Piping
Gas Test 1,70
Appliances
Final
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)
COMMENTS:
l
I
:.._�.<�4..'n;:�l.:(/�.iF: r..t/:4�i✓..•7?.O.•NY�/is�ixu n..rei✓.�im.i r�.nnmi.s.�owi.�.r�......�..�.�.....�..�,._.�.�__.�.._.�.-.-.-.-..
'
INSULATION CERTIFICATE 1-20, O
This is to certify that insulation has been installed in conformance with the imrrent energy
regulation, California Administrative Code, Title 24, State of California, in tie building located
81-893 SUN CACTUS LANE LOT 1020, LA 4UINTA 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: f
l/F/6/C/F/l/I/X/J%A%O.'/I/f/L"/F//7l/d/iSs/C///,E/Fl!/i//7l/O///F/p%!/J�%I.fF/!✓P/iAl/IFF/J7!/ll%/d/!/qT/F/6//7F/fit'11)Y7IYl/l/.r/1.%'.fF/I/!/R///1/r/1yt/1%/%/%1'iIYF.:/M/1/,/%//I,'F/F/i/f//'r'
9
Installation Certificate: Residential CF -6R
.Site Address
81-893 Sun Cactus Lane
1. BUILDER INFORMATION
Shea Homes - Trilogy - LaQuinta
60311 Trilogy Pkwy
La Quinta, CA 92253-7642
INSTALLING CONTRACTOR:
2. PROJECT INFORMATION
DISTRIBUTION
TYPE
Flexible Ductwork
in Attic and i
Between Floors
DUCT OR PIPING R -
VALUE
Flexible Ductwork
Will have a R -Value
of 4.2 or Better
PERMIT #
SUBDIVISION: Trilogy @a, La Quinta
CITY: La Quinta
COUNTY: Riverside
WEST PAC AIR CONDITIONING
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.
&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
Signature Installing HVAC Contractor
DATE: S-