04-5141 (SFD)BUILDING & SAFETY DEPARTMENT
c�
R7 . Bp� x 150 (760) .777-7012
OF 7=8=495CALL'pi� �MPlco FAX (760) 777-7011
LA QU N CA 1IFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
Jul- 2 ub�'
CITY ®F �QUINva BUILDING PERMIT
FINANCE DEPT.
`'Applicat•ion `Number, ...
. . . f -04-00005.141_ J
Date ' 6/25/0`4
Property Address,
L`50245 VIA AMANTE
APN:
772-390-034- - -
Application description
. . . DWELLING - SINGLE FAMILY
ATTACHED
Property Zoning
. . LOW DENSITY RESIDENTIAL
Application valuation .
. . . 186025
Owner
Contractor,
------------------------
R J T HOMES
------- - -
RJT HOMES LLC
1425 E UNIVERSITY DR
1425 E. UNIVERSITY
DRIVE
PHOENIX AZ
85034 PHOENIX
AZ 85034'
WCC: STATE FUND
WC: 1583906
10/01/04
CSLB: 690645
06/30/<04
-CCC: A -B
1
------ Structure Information SATT
-----
Construction TypeTYPE-V
- NON RATED
Occupancy Type . . . .
. . DWELLG/LODGING/CONG <=10
Flood Zone
NON -AO FLOOD ZONE
Other struct info . . .
. . CODE EDITION
.2001 CBC
GARAGE SQ FTG
457.00
PATIO SQ FTG
867.00
TOT ELIGIBLE
NO
NUMBER OF UNITS
1.00,
FIRST:FLOOR SQ FTG
2894.00
----------------------------------------------'------------------------------
Permit BUILDING
PERMIT
Additional desc
Permit Fee . . . .
944.00. Plan Check Fee
613.60
Issue Date . . . .
Valuation . .
. . 186025
Qty Unit Charge
Per
Extension
BASE FEE
639.50
87.00 3.5000 THOU
BLDG 100,001-500,000
304.50
--------------------------------------------=
Permit . . . . ... MECHANICAL
-------------------------------
Additional desc
Permit Fee
72.00 Plan Check Fee
19.88
Issue Date
Valuation . .
0.
Qty Unit Charge
Per
Extension
BASE FEE
15.00
,_4
P.O. BOX 1504 • VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 4INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 7 W Date: % ' g 3_33
Applicant:
Applicant's Mailing Address:
--Architect or Engineer:
IArchitect or Engineer's Address:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 Professionals
Code, and m - 4 -License in full rce and effect. tb (l O6_!r S
cense Class — Tense No.
/Date 4—,740- O 5ntrador F 3C
OWNER$ ILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5; Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisiors of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects.
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U 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 and Professions Code: The Contractors' State License Law does not apply to en owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
.0 1 am exempt under Sec. , BA P.C. for this reason
Date Owner
WORKERS' 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
is s ed. M rkers mpensatton inAurdnce carrier and policy nu r
aTer 4I olP licy Number ' Q 9
—I certify that, n the performance of the work for which this permit is issued, sh�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.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATIOA COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS. ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND AT—ORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Buiding and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, anc the applicant, each agrees to, and shall, defend, indemnity and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to enter upon the above-mentioned property for inspection purposes.
., _Date '� 3 VZ1Signature (Applicant or Agent): �j
.1/
Page
2
'Application Number
. . 04-00005141
Date
.6/25/04
Qty Unit
Charge
Per
Extension
1.00
9.0000
EA
MECH
FURNACE <=100K
1.00
9.0000
EA
MECH.B/C
<=3HP/100K BTU
9.,00
.00
16.5000
EA
MECH
B/C >3-15HP/>100K-500KBTU
.00
5.00
6.5000
EA
MECH
VENT FAN
32.50
1.00
6.5000
EA
MECH
EXHAUST HOOD
6.50
----------------------------------------------------------------------------
Permit. . . .
ELEC-NEW RESIDENTIAL
Additional desc
Permit Fee .
. . .
125.43
Plan Check Fee
3.76
Issue'Date .
. . .
Valuation . . . .
0
Qty Unit
Charge
Per
Extension
BASE
FEE
15.00
2894.00
.0350
ELEC
NEW RES - 1 OR 2 FAMILY
101.29
457.00
.0200
ELEC
GARAGE OR NON-RESIDENTIAL
9.14
----------------------------------------------------------------------------
Permit . . .
. . .
PLUMBING
Additional desc
Permit Fee
207.00
Plan Check Fee
51.75
Issue Date .
. . .
Valuation
0
Qty Unit
Charge
Per
Extension
BASE
FEE
15.00
23.00
6..0000
EA
PLB
FIXTURE
.138.00
1.00
15.0000
EA
PLB
BUILDING SEWER
15.00
1.00
7.5000
EA
PLB
WATER HEATER/VENT
7.50
1.00
3.0000
EA
PLB
WATER INST/ALT/REP
3.00
1.00
9.0000
EA
PLB
LAWN SPRINKLER SYSTEM
9.00
6.00
.7500
EA
PLB
GAS PIPE >=5
4.50
1.00
15.0000
EA
PLB
GAS METER
15.00
------------------------------------------
Permit . . .
. . .
GRADING PERMIT
----------------------------------
Additional desc
,Permit Fee
15.00
Plan Check Fee
.00
Issue Date .
. . .
Valuation
0
Qty Unit
Charge
Per
Extension
BASE
FEE
15.00
------.---------------------------------------------------------------=------
Special Notes
and Comments
SFA - LOT 141.
PLAN P1B.
PERMIT
DOES -NOT
I
v
Page 3
Application Number
I
Page 3
Application Number
. . . . .
=
04-00005141 Date
6/25/04
------------------------
Speci.al Notes and Comments
----------
---------------------------
--------------
INCLUDE BLOCK WALL,
POOL, SPA
OR
DRIVEWAY APPROACH.
--
------------------------
Other Fees
-----------
---------------------------
ART IN PUBLIC PLACES -RES
------- - - - - -
.00
DIF COMMUNITY CENTERS -'RES
68.00
DIF CIVIC CENTER - RES
229.00
ENERGY REVIEW FEE
61.36
DIF FIRE PROTECTION -RES
78.00
GRADING PLAN CHECK FEE
.00
DIF LIBRARIES.- RES
158.00
DIF PARK MAINT FAC - RES
3.00
DIF PARKS/REC - RES
352.00
STRONG MOTION (SMI) - RES
18.60
DIF STREET MAINT FAC=RES
15.00
DIF TRANSPORTATION - RES
1098.00
Fee summary
Charged
Paid Credited
Due
Permit Fee Total
1363.43
.00 .00
1363.43
Plan Check Total
688.99
.00 .00
688.99
Other Fee Total
2080.96
.00 .00
2080.96
Grand Total
4133.38
.00 .00
4133.38
I
L
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC.TESTING (Page I of 7) :CF -41R
PALMILLA PH 9 DATE TESTED 7-07-05
Project Title Date
50-245 VIA AMANTE LA QUINTA, CA. 92153 RJT HOMES .
Project Address Builder Name
CHAD MEYER 760-564.-6555OCOTILLO. P-1 3 UNITS
Builder Contact Telephone Plan Number
RICHARD KROWN 760-250-2084 GROUP 7
HERS Rater /�Telephone Sample Group Number
#CCNRK613292 07-14-05 LOT 141
Certifying Signature Date Sample Lot Number,
Firm: DESERT ENERGY SERVICES LLC HERS Provider: CHEERS
Street Address: P.O. BOX 621 City/State/Zip: . RANCHOMIRAGE; CA. 92270
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested ® Approved as part of sample testing but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply
with the diagnostic tested compliance requirements as checked on this form.-
El
orma❑ The installer has provided a'copy of CF -6R (Installation Certificate.
❑ Distribution system is fully ducted(i.e., does not use building cavities as plenums or platform returns in lieu of ducts) .
❑ Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth
backed,, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage.Testing Results (Maximum 6% Duct•Leakage) .
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here .
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _
Check Box for Pass or Fail (Pass =6% or less) ❑ ❑
Pass '' Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑ ❑
8
D
ENERGY
s. - CAD EC
5w "1
—
P0. Box 621
Ph/Fax (760) 564-2044
Rancho Mirage, CA 92270
Cell: (760] 250-1852
Email: DESNRG AAOL.COM
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC.TESTING (Page I of 7) :CF -41R
PALMILLA PH 9 DATE TESTED 7-07-05
Project Title Date
50-245 VIA AMANTE LA QUINTA, CA. 92153 RJT HOMES .
Project Address Builder Name
CHAD MEYER 760-564.-6555OCOTILLO. P-1 3 UNITS
Builder Contact Telephone Plan Number
RICHARD KROWN 760-250-2084 GROUP 7
HERS Rater /�Telephone Sample Group Number
#CCNRK613292 07-14-05 LOT 141
Certifying Signature Date Sample Lot Number,
Firm: DESERT ENERGY SERVICES LLC HERS Provider: CHEERS
Street Address: P.O. BOX 621 City/State/Zip: . RANCHOMIRAGE; CA. 92270
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested ® Approved as part of sample testing but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form comply
with the diagnostic tested compliance requirements as checked on this form.-
El
orma❑ The installer has provided a'copy of CF -6R (Installation Certificate.
❑ Distribution system is fully ducted(i.e., does not use building cavities as plenums or platform returns in lieu of ducts) .
❑ Where cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth
backed,, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage.Testing Results (Maximum 6% Duct•Leakage) .
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here .
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _
Check Box for Pass or Fail (Pass =6% or less) ❑ ❑
Pass '' Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑ ❑
8
!,INSTALLATION CERTIFICATE CF -6R
56-245 Via Amante
Site Address
Permit
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The information provided on this form is
required; however, use of this form to provide the information is optionl.) After completion of final inspection, a copy must be provided to the building
department (upon request) and the building owner at occupancy, per section 10-103(b).
HVAC SYSTEMS:
Heating Equipment
Equip. Type
(pkg. heat CEC Certified Mfr, Make &
pump, etc.) Model Number
FAU CARRIER 58STX090116
FAU CARRIER 58STX070112
COIL FIRST CO 24 HXO
Cooling Equipment
Equip. Type
(pkg. heat CEC Certified Compressor Unit
oumo. etc.) Mfr. Name and Model Number
A/C COND. CARRIER 38BRC048000
A/C COND. CARRIER 38BRC030000
HEAT PUMP CARRIER 38BYCO18
1 Z reads greater than or equal to
# of
Efficiency
Duct
Duct or
Heating
Heating
Identical
(AFUE,etc.)'
Location
Piping
Load
Capacity
Systems
[>_CF -]R valuel
(attic, etc.)
R -value
(Btu/hr)
(BTU/Hr)
1
80.0%
ATTIC
R-4.2
90,000
1
80.0%
ATTIC
R-4.2
70,000
1
# of
Effeciency
Duct
Cooling
Cooling
Identical
(SEER, etc)'
Location
Duct
Load
Capacity
Systems
[>_C17 -1R value]
(attic, etc.)
R -value
(Btu/hr)
(BTU/Hr)
1
12
ATTIC
R-4.2
48,000
1
12
ATTIC
R-4.2
30,000
1
12
ATTIC
R-4.2
18,000
I, the undersigned, verify that the equipment listed above is: 1) is the actual equipment installed, (2) equivalent to or more efficient than that specified in the
certificate of compliance (Form CF -1R) submitted for compliance with the Energy Efficiency Standards for residential buildings, and (3) equipment that meets
or exceeds the prgpriate req irein is for manufactured devices (from the Appliance Efficiency Regulations or Part 6), where applicable.
AMPAM LDI Mechanical
Sharne Au ey 2/4/2005 HVAC Subcontractor (Co. Name)
OR General Contractor OR Owner
WATER HEATING SYSTEMS:
Water CEC Certified Distribution If Recir- Rated Input Tank Efficiency Standby External
Heater Mfr Name & Type (Std, culation, # of Identical (kW or Volume (EF, RE) Loss (%) Insulation R -
Type/# Model Number Point -of -Use) Control Type Systems Btu/hr) (gallons) value
FAUCETS & SHOWER HEADS:
All faucets and showerheads installed are listed in the Commisions Directory of Certified Faucets and Showerheads,
pursuant to Title -24, Part 6, Subchapter 2, Section 111.
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, I have 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.
Signature, Date
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
RCR COMPANIES '
Plumbing Subcontractor (Co. Name)
OR General Contractor OR Owner
INSTALLATION CERTIFICATE (Page 3 of 13) CF -6R
P7.4M 11 . PAs e-- a lob'
Site Address Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM) k0_
Fan Flow
if Fan Flow is Calculated as 400 efm/ton x number of tons, or as 21.7 x Heating Capacity
In Thousands•o( Btu/hr, enter calculated value here
If fan flow Is measured, enter measured value here 0
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction < 0.06 Pass
ss Fail
❑ For AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
O Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No O Visual Inspection of Duct Connections a o
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion, Valve is installed and Access is -provided for inspection;
Yes is a pass O
❑ DUCT DESIGN Pass Fall
ACCA Manual D Design calculations have been
1. O Yes- O No completed, Duct Design Is on the plans'and duct Installation
matches plans.
2. O Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, O O
verified fan flow matches design from CF -IX Pass Fail
Measured Fan Flow=-
Yes for both 1 and 2 is a Pass
❑ I, the undersigned, verify that the above diagnostic test results and the work I performed associated with the tests) is in conformance
with the requirements for compliance credit. [71e builder shall provide the HERS provider a copy of the CF -6R signed by the builder
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. J -
} q'oS11IeC,r!c`nI16CL 1
Tests ignature, Date Installing Subcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY TO; Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms August 2001 A-25
' INSTALLATION CERTIFICATE (Pape 3 of 13)
CF -6R
:P ;,')) •. P64z e_ a
Site Address Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM)
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton 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 _LLQ0
-
Leakage Fraction.= Test Leakage/(Measured or Calculated Fan Flow) _ -01Q57
O
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 (CFM)
CHECK AFTER FINISHING WALL:
O Yes O No O Pressure pan test or House pressurization test
O Yes O No O Visual Inspection of Duct Connections
C ❑
A
Pass Fall
O THERMOSTATIC EXPANSION VALVE (TXV)
O Yes O No Thermostatic Expansion Valve is installed and Access is - provided for inspection
Yes is a pass
%� 0
O DUCT DESIGN
Pass Fall
ACCA Manual D Design calculations have been
1. O Yes O No
completed, Duct Design Is on the plans and duct installation
matches plans.
2. O Yes O No TXV is installed or Fan flow has been verified. If no TXV,
0
verified fan flow matches design from CF -IR.
Pass Fail
Measured Fan Flow -
'
Yes for both I and 2 is a Pass
O I, the undersigned, verify that the above diagnostic test results and the work 1 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 -6R signed by the builder
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. ]
— R4
Tests ignature, Date Installing Subcontractor (Co. Name) OR -
Perforated General Contractor (Co. Name)
COPY T0: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms August2001 A-25
- INSTALLATION CERTIFICATE - (Page 3 of 13) CF -6R
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCUON
Pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM) -3—a
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity.
In Thousands'o( Btu/hr, enter calculated value here
If fan flow Is measured, enter measured value here _12-0-0
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) =12i.0 S3 t7
Pass if leakage fraction <0.06 Pass Fall
O For AEROSOL TYPE SEALANTS ONLY -The following diagnostic tesdng.was.completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING 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
O THERMOSTATIC EXPANSION VALVE (TXV)
O Yes O No Thermostatic Expansion Valve is installed and Access is - provided for inspection
Yes is a pass O
O DUCT DESIGN Pass Fall
ACCA Manual D Design calculations have been
1. O Yes O No completed, Duct Design Is on the plans and duct Installation -
matches plans.
2, O Yes O No TXV is installed or Fan flow has been verified. If no TXV, o
verified fan flow 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 sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. J
Q—O S 1 -Dy— IP 2C _CA_tt 1 tC I
Tests ignature, Date Installing Subcontractor (Co. Name) OR -
Performed General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
a
r
Compliance Forms August2001 A-25