0109-016 (SFD)f LICENSED CONTRACTOR DECLARATION
.fiNirreby 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
Professionals Code, and my License is in full force and'effect.
License # Lic. Class Exp. Date
Date"� 4 " .rf 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).
()'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.
I X Cid Ja• �lA
J (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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. �
p �
Date: � Applicant "%� : A •�� � � c-
,r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up -to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety';
for a permit subject to the conditions and restrictions set forth on' his' 's
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
o & hold harmless the City of La Quinta, its officers,- agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
per or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the buildingr-, ,
construction, and hereby authorize representatives of this City to enter upon'"
the above-mentioned property for jinspection purposes.
' Signature (Owner/Agent) -' . a•oN Date �'r' "'C.t✓
t BUILDING PERMIT'PERMITk
DATE ; ^y 1r VALUATION LOT TRACT
,�• �/ c... �?!''�+f,►:g84i11 �4D '7•�, .�tR.fiifrtei
JOB SITE
ADDRESS.
APN
.50-M. WAALIM4
-•M,Ms
OWNER
CONTRACTOR / DESIGNER / EN (NEER
J 425 R UN1.OT11 TARIV19
Lk CSA 92253
.13kX3'maSC tom: 85034
CMS 4990
USE OF PERMIT
r
M2»1G�L14; FAMLY JkTTACEM
SFA -1,01' 71 PLAN PIA. Pial IT 00322 kTar FNO';LUM. HIMC K WA,L.; A
Po0,(..WP A.,0R k')R1VEWAY APPROACH
H
1'.RAC`I' CONSTRUCTION d,; .94.00 BF
iIRQr3-lil'ATIO997.00 SY
t6�CIl C&RP'�3RT 457,00 SW
"XMINA- ? COSI' 011'(' 0KY1RUCITiO
1/9XI-50 '
MO3f1Tt`7" � SUMAAR ' 11
. .
PLAN CHECK FFR 101-0-00-439-318
MACHANI.CAL VIM 101.004 -421 -OW 579,30
F,Lii.CTWCAL 029 }O��/3tY3�w$�f7-ib04 $;1tt!i,dS
1ta1.11MBYRO Isla 101"000.419-M) $8.0610!
STRONO Mtix9'lON ME - RE +DO 101-000--W-000 $1794
O3fi.E1.DI . MR 101-000.423.000
• L• ,.
9TiaW,11013•>.� ,13 PLAN f."..I.b1;:C K
Du
1:XISS P:�A'aID !M
$0.00
. .x3
-
0 6 2001 •- , .-
SEP 11
• ' .. � .
$5
M_MT :VM WE OW
l re,
CITY OF LA QUINTA
- FINANCE DEPT. .
RECEIPT
DATE?/ �,
BY
DA INAL D
INSPECTO
1
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs l _� O/
Forms & Footings cy
e(
Underground Ducts
Ducts
Slab Grade
Steel
Return Air
Combustion Air
Roof Deck
.�2(y—d
/
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
1 l —U
%�
Compressor
Vents
Insulation l� —2�—(] �GGt,
Fireplace P.L. -
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
j -J
Final
Final <--
BLOCKWALL APPROVALS
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
_
Waste Lines �-% O !
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
cT=L_
_
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) r -p
! y LATION CERTIFICATE (Page 3 of 13) CF -6R
Site Address Permit Number /~ n Lp
DUCT LEAKAGE, AND DESIGN DIAGNOSTICS S -p —09G7_ 'th
DUCT LEAKAGE REDUCTION
• - Y
Pressurization Test Results.(CFM ® 25 PA) Test Leakage (CFM) -.a
Fan Flow
If Fan Flow is Calculated as 400 cfm1ion x number of tons, or as 21.7 x Heating Capacity
In Thousands of Btu/.hr, enter calculated value here
If.fan flow Is measured, enter measured value here
Leakage Fraction =. Test Leakage/(Measured or Calculated Fan Flow) _ p
Pass if leakage fraction <0.06 Pass Fail
O. For AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed: '
Duct Fan Pressurization at rough -in measured leakage (CRM)
CHECK AFTER FfN]SHING WALL:
O. Yes O_ No O Pressure pan test or House pressurization test
O Yes O No O Visual Inspection of Duct Connections o 0
Pass Fail
B THERMOSTATIC:EXPANSION VALVE (TXV)
Yes O No Thermostatic Expansion Valve is installed and. Access is -provided for inspection
Yes is, a pass O
O DUCT DESIGN Pass Fail
:ACCA Manual D Design calculations have been
1.. O Yes ❑ No completed, Duct Design Is on the pians and duct installation
matches plans:
2: O Yes O No. TXV is installed or Fan flow has beenverifled. If no TXV, O o
verified fan now matches design from CF -IR. Pass Fail
Measured Fan Flow=
Yes for both 1. and 2 is a pass'
O I, the undersigned,verify that the above diagnostic test results and the work I performed associated with the test(s) is in conformance
with the requirements for compliance credit. (The builder shall.provide the HERS provider a copy of the CF -611 signed by the builder
employees or subcontractors certifying that diagnostic testing and installation meet the requirements for compliance credit. ]
i7 .0
Testi
a tire, Date Installing Subcontractor (Co: Name) OR
Perfomt<d General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if" applicable)
Building Owner at Occupancy
Conipllance, Forms. August 2001 A-25
t
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 at:
50-095 VIA ALDEA,LOT 75,LA QUINTA,CALIFORNIA
CEILINGS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE : BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-21
GEN L C NT, CT : RJT ES LICENSE # 1
B TITLE:t��'�� CCGU)
P 3�N SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003