0401-111 (SFD)LICENSED CONTRACTOR DECLARATION '
,affirm under penalty of perjury that I am licensed under provisions of
ha'ier 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
690645 B P41C d;. 6/10/04
-Date r `*' !21 1 Signature of Contractor
J
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 I , 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:
() l,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
Se tion 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 STATE FUND Policy No. 13,33906.91
J (This section need not be completed if the permit valuation is for $100.00 or less).
() (;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.
Date: 7 -'r r !',= / Applicant o�'_••. ,
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 a d 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 inspection purposes. ,� ^
R y`.
Signature (Owner/Agent)I 1. = • *' r. Date f -' x`'” •�
lO_
BUILDING PERMIT PERMIT# ,
DATE VALUATION LOT TRACT `,hb
1' ...y 4?'
JOB SITE
ADDRESS �W-4901VIA AMAN7Z
APN
712-050-11W7
OWNER � -
CONTRACTOR/DESIGNER/EN (NEER,
PID BOX 8? 0
1 425 T 'U;1IV E+' MT'DPJVr�
t.AQI�ITA CA .92253
PHORUix Ai'„ 85034
-
(602)257 11656 CBT -0 4990
USE OF PERMIT
sr.k - i T 1:, P1 A -M P2B; PERMIT DOES NOT INCLUPE POOL, SPA,
BLOCK K TAIt.'i1, A, OR DRIVEWAY AF'PRC?,P,CH
TRACT CONSTRUCTION ;6,191.00 SF
PORCH/PATIO 346.60 Sit`
01MAGUC,ARPORT 833,00 9F
RISTMIATED COYUIP COIV MU •t➢N
1,91, AX50
FFMM' M UUMMARY ".
COI STRUCTION FEE 101.066.418a000 $969,30
PLAN CHICK Vh2 101-0100-4391.318 $822.46
MECHANICAL.".B 101.000.4.21-000 $103:00
Ei<LCTRICALFFM 101-000-4210-000
1PLUMS311 O FEE 101.000.419.000 X230.40
STRO ND MOTION IEE , RE II, 101-000-U 1 -Gaff $19.14
GRADING TRE 1101-000.423-000 815,00
DEVELOPER IMPACT FE �7,OOI.flA
-
L1<33 FIZ& AMD M— 04
$0.00
i -
J41V 28
Or
RECEIPT
DATE 1 xr
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
��� _
Return Air
Steel
3< <
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
g'- 2 —
F.A.U. '
Framing
_
Compressor
Insulation
cb-
Vents vz
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali 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
3
Encapsulation
Gas Piping
Gas Test
j
Appliances
Final
COMMENTS. �•2 3--z3
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
CERTIFICATE OF FIELD VERIFICAUCIN AND DIAGNOSTIC TESTING (Page I of 7) CF4R
PALMILLA PH -6 09-14-04
Project TitleDate
50 T & JEFFERSON _ R J T BUILDERS. _
Project Address-- Builder,Namc
D'ARRELL MORGAN 760-275-8230 ACACIA P-2 3 UKITS
Builder Contact Telephone Plan Number
RICHARD: KROWN 760:250=1852 GROUP 4
HERS Rater Telephone
— #CCNRK613292 09-14-04 LOT # 13
Certifying Signature Date Sample House Number
Firm:DESERT ENERGY SERVICES HERS Provider: CHEERS
P.O. BOX 621 RANCHO MIRAGE CA. 92270
Street Address: _ _ �. _ City/StatelZip: 4
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.
❑ The'installe'r has provided a copy of CF -6R (Installation,Certificate.
El Distribution system is fully ducted (i..c.; does not use building cavities as plenums or platform returns in lieu of ducts)
❑ Where cloth backed. rubber adhesive duct .tap "e is installed, mastic and drawbands are, used in combination with cloth
backed. rubber adhesive duct tape to seal leaks at duct corthections-
❑ MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE -CREDIT
Duct Diagnostic Lcakage Testing Results (Maximum 6% Duct Leakage)
Measured
z Duct Pressurization Test Results (CFM L25 Pa) values
Test Leakage Flow in CFM
If fan flow is calculated as 400efm/ton x number of tons enter calculated
value here
If fan flow is measured,enter measured value here
Leakage Percentage (1 00 x Test LeakagelFan Flow) _
Check Box for Pass or Fail (Pass=6%'or less)
❑ THERM,OSTATIC EXPANSION VALVE (TXV) _ J
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access:is
prodded for inspection
Yes is a pass
❑ ❑
Pass Fail
❑ ❑
Pass Fail
LATi0Pqn,._t.�LRTMCATE_ CF -6R
SIte.Address Permit Number
.DUCT LF_AK-kGE AND DESIGN DL4GI OSTIES
,Q QQ—LEAKAGEREDUCTION
Pressurization Test Results (CFAI Q 25 PA) Test Leakage (CFM)
Fan Flow
If Fan Flow is Calculated as 400 cfrrdtor, x number of tons, or as 21.7 x Hearing Capacity
In Thousands of Bkdhr, enter calculated value here
If fan flow is measured, enter measured vaiue.here
Leakage Fraction= Test Leakage/(Measured or,Calculated Fan Flow) =
o
Pass if leakage fraction < 0.06
Pass Fail
0 F AEROSOL. TYPE. SEALANTS ONLY -The .following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured. leakage (CFM)
CHECK AFTER FINISHMIG 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
K THER OSTATIC EXPANSION VALVE n–All
:Cr7es 0' No. Thertrostatic Expansion.Valve is installed. and Access is.,.provided for inspection .
Yes is a pass
0
ss r4 ail
DESIGN
a DUCT DFsrc
ACCA Manual D Designcalculations 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,
t7 O
verified fan flow matches design from CF -k
Pass Fail
Measured Fan flow =
Yes for both 1 and 2 is a Pass:
O 1, the undersigned. verify that the above diagnostic tat results and the %vork I.performed associated wiih the test(s) is in:cotiformance
with:the requirements -for compliance credit. ['tire builder shall provide the HERS providera copy of the CF -6R signed by the builder
employees or subcontractors certifying that diagnostic testing and installation meet the requirements for compliance erediL )
Tests `Signature, Date ' 'Installing Subcontractor (Co. Mame) OR
Perforrrud • General Contractor (Co. game)
COPY TO: Building Department
HERS Provider '(if applicable).
Building Owner at Occupancy
Compknca:Forms August 2001
A-25
w
INSTALLATION ` ARTIFICE TE (Page `.3) CF -6R
Site Address Permit Number
DUCT Lt.AKAGE A!ND DESIGN DIAGNOSTICS
D UC: r LkAKAGE RED
Pressurization Test Results (CFM (0,25 PA) Test leakage (CFM) ZO'
Fan Flow
If Fan Flow is Calculated as ;00 cfmhon'x number of tons, or as 21:7 x Heating Capacity
in Thousands of Btulhr, enter calculated value here
It. fan flow is measured; enter measured value, here
Leakage -Frac lion= Test Ixakage/(Measured or Calculated Fan Flow) = o
Pass if leakage fraction < 0.06 Pass - Fail
❑ ForAEROSOL, TYPE SEALANTS ONLY -The following diagnostic testing was compleied:
Duct Fan Pressurization at rough -in measured leakage{CFK
CHECK AFTER FINISHLNG WALL:
❑ Yes ❑ No ❑ -Pressure pan testor House pressurization test
p.Yes O No 0 Visual Inspection of Duct Connections o. 0
Pass: Fail
�VTHERVIOSTATIC EXPANSION VALVE (TXV)
:Yes ❑ No Thermostatic Expansion Valve is installed and Access is -provided for inspection.
Yes is a pass �� 0
❑ DUCT DESIGNPass Fall
ACCA Manual D Design calculations: have been
I: ❑ Yes ❑-NO completed, Duct Design Is on the plans and duct Installation
matches plans.
2. b Yes ❑ No . TXV is installed or Fan flow has been verified. If no.TXV, 0 O
verified' fan, flow_ matches design from CF -IR. Pass. Fail
Measured Fan Flow=
Yes for both I and 2 is a Pass
❑ 1, the undersigned; verify that the above,dinghostic test results and the work I performed associated with the tcst(s) is in conformance
with the, requirements for compliance credit. [The builder shall provide the HERS providera 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
AV
Tose ign cure, Date- . Installing Subconiractor.(Co.Name) OR'
Perfomxd General Cantractor (Co. Name)
COPY TO: Building Department _
HERS Provider '(if' applicable)
Building OwTer at,Occupancy.
Compliance Forms August 2001 A-25