0401-110 (SFD)LICENSED CONTRACTOR DECLARATION .
I hereby affirm under penalty of perjury that I am licensed under provisions,of
Chapter9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
x License # Lic. Class Exp. Date
t � ,
6190645 BWC A 6130104
Date k , '_-'t) Signature of Contractor ^'' -� . .lit
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 STAT•p �iJ1�1U Policy No. ! 183flfl6-Oz
(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. ,
Date: ' /- Applicant
W" 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
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'ente'r upon
the above-mentioned property r inspection purposes. i` 4''
Signature (Owner/Agent) - f Datel
�^ p
Y
BUILDING PERMIT PERMIT#
040j,-110
DATE VALUATION LOT TRACT _
e'. -` : -(,.) / 14 29£I9S-�
JOB SITE+?x s:,'3 F' ,,,
APN
ADDRESS ' +
772.050-W7
OWNER _ _ _
CONTRACTOR/ DESIGNER/ EN (NEER - —
013W.11 I U14
1n' TP ' riVi!'.�v' I s, We.
PO FOX E1 ID
1425 ,B, 'C7NNFURSErYDRIVE
L. A ( UINTA C4..92253
PRO IX AZ 85034
'-*
(602)257.1656 CPQ 4990
USE OF PERMIT
13NOIXrAit MYATI ACEDF-D
SPA - LLT 1.4, PLAN P3A. PERMIT DOES NOT INCLUDE POOL, SPA, '
BLOCK WALLS, C' R DWSWAY APPROACH .
TRACT C014S'I'F. UCT ION 3,204.00 8I•
PORCH MATZO 773.00 SF
GA1b. iC4UCARPORtT S613100 S?
FS'TA1"MD C09r OF COPS'T.R.U£yrrlOW
P$7 P*M' Yj%' 4 Sd�'.Iii.�P.J$A,1ZY
CONSTRUCTION FEE 101-000-438-000 $999.50
PLAN f HEICK FEE 101.000-439-315 $323.57
MECiiANICA1. FEE 101-100-421.000 S"i3<t)0
X1,1..r TRIC:AL PU 101-000-420-000 320130
PLUZ# BINO FEE 101.000-419.000 $190.00
STRONO MOT1014 FEE, RESIi.3 101-000-241.000 S) 9.9r),
GRADING 172,Z 101-000.423.000, aIS.00
DEVELOPER IMPACT FEE
.RM-TOTJT., C0MMUGt3024JWD PLAW CHEC'1.'..
$4,313.34
IMS PRE-PA"I:C?'FIM'
x;0,00
A\
n PIUMM FEES DUENOW
8 1
00
F
AFW�
RECEIPT
DATE'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
.OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms& Footings
u
Slab Grade
Return Air
Steel
,3 - j _
Combustion Air
Roof Deck
y-20- y
Exhaust Fans
OX to Wrap
F.A.U.
Framing
_ �/
Compressor
Insulation
7 7 - Al
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
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
3'' - !✓
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-3
'Encapsulation
Gas Piping
-
Gas Test
Appliances
Final
Final �
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit AO
Rough Wiring _
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
U lity,Notice (Penn) -
COMMENTS: t'. LH.-. E-,;/ t✓ �,c�,��/ 3 �z—`J ,�S
��C� u+17,4n�7�'l.�•d�- c�4� ��y
CEWITFICA TE.OF FIELD'VERWICATION.AND DIAGNOS'T'IC TESTING (Page 1. of 7) CF4R
PALMILLA PH -6 Q9-14-04
Project Title Date
50, TH S JEFFERSON R J T_BUILDERS
� Project Address � .— — — � _ Builder Name,
DARRELL MORGAN 760-2754230 PALO BREA P-3 2 UNITS _
a Builder Contact Telephone Plan Plumber — s —
RICHARD KROWN 760-250-1852 GROUP 4
HERS Ratcr — Y — Telephone _
#CCNRK613292 09-14-04 LOT # 14
Certifying Signature Date Sample House Num Cr
DESERT ENERGY SERVICES CHEERS
Firm: . ® — HERS Provider:
j. Street Address: P•O. BOX 621 — _ Cite/State/Zip: RANCHO MIRAGE CA. 92270'
Copies to: Builder, ETERS Provider
HERS RATER COMPLIANCE STATEMENT
The house Nvas: ❑ 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 installer has provided. a copy of CF -6R (lnstallation.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 ducttappe is installed, mastic and drawbands are used in combination with cloth
backed,.rubber adhesive duct tape to seal Ica ks at duct connections
-
0 MINIMUM REQUIREMENTS.FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct ;Pressurization Test Results (CFM (A_2'5 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 (I 00x Test Leakage/Fan Flow) _
Check:Box for.Pass or Fail (Pass=6% or less) ❑ ❑
Pass 'Fail
4❑ T14ERMOSTATIC EXPANSION VALVE (TXV.)
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑
Yes is a pass Pass Fail
:l T T 1. I*\T!\,�kT /.-!.. "..TYTTYI.1 TT'
DUCT LEAKAGRAND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCTION
Pressurization T6UResults (CFM ® 25 PA) Test Leakage (CFM)_d�
Fan Flow
If Fan Flow is Calculated as 400.efmhon x number of tons, or, as 21.7 x Heating Capacity
in Thousands of BtLAr, enter calculated value here.
If fan flow Is"measured; enter measured value here
Leakage Friction =Test Leakage/(iMeasured orCalculated Fan Flow) =
a
Pass if,leakage fraction <.0.06
Pass Fail
G For AEROSOL TYPE SEALANTS ONLY =The following diagnostic testing %rias completed:
Duct Fan Pressutiiarion at rough -in measured leakage.(CF\14) '
'CHECK AFTER F NI ISHINjG WALL:
O Yes 0 No O Pressure.pan test or House pressurizarion test
'. O Yes;. O No 0 Visual inspection.of Duct Connections
a o
Pass Fail
THERMOSTATIC EXPANSION VALVE (TW
Yes O No Thermostatic Expansion Valve is installed'and Access is -.provided for inspection
5.
Yes is pass
g
/ O
O'DUCT DESIGN
Pass Fail
ACCA Manual D Design calculations have been
I. ❑Yes O No completed; Duct Design is on the plans and duct installation
f matches plans. t
l
2.'O Yes O' No TXV is installed or Fan flow has been -verified. If no•TXV,
.verified fan flow matches design from CF -IR
Pass Fail
Measured Fan Flow=
Yes for both 1 and 2 is a Pass
O 1, the undersigned, verify that ihe•rtbove 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. -6R signed by the builder
employees or subcontractors'certifying that diagnostic testing and installation.meet the"requirements for'compliance &edit. ]
Tess — 9igtr5tth Datt ' Installing•Subcontractor (Co. Name) OR
Pcrfornied General Contractof (Co. Name) .
COPY TO: Building Department
HERS Provider or. applicable) ,
Building Oyrcr at Occupancy
Compliance Forms August'2001
A-25
O. 1, the undersigned, verify that the above diagnostic test resulrs and the work I performed associated with the tests) is ineonformance
with the requirernents for compliance credit: Me 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 ]
All
Tests , t t Date Insialling•Subcontractor (Co: Name) OR
PerromKd General Contract or.(Co. Name),
COMM Building:Department
HERS Provider (if'applicable)„
Building Owner at Occupancy
Compliance Forms August2001• A-25
L TS.TALLATIONT' C'-"�.IJATUICATE (Page -3L I)_
CF -6R . .
S e:Address Permit
Number
DUCT LEAKAGE A1ND DESIGN DIAGNOSTICS
llUC'1' LEAKAGE REDUCTION
Pressurization Test Results (CFM @ 25 PA) Test Leakage,(CFM)
Fan Flow
If Fan Flow is Calculated as 400 cfrrdton x number of tons, or 21.7 x Heating Capacity
in Thousands of.Btulhr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) =
r o
Pass iFleakage fraction <.0.06 .,
Pass 'Fail
13 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
o. o.,
Pass. Fail
$ .THERMOSTATIC EXPANSION VALVE (TXV)
g Yes Q. No Thermostatic.Expansion.Valve is installed and Access is - provided for inspection
Yes, is a pass
i8 0 .
Pass Fail.
❑ DUCT DESIGN
'
ACCA Manual U Design calculations have been
1. O Yes O No completed;lDuct Design is on the plans and duct installation
matches plans.
2. O Yes O No TXV is installed or. Fan:low. has been verified. If no-TXV,
O t]
Pass Fail
verified fan flow matches design from CF -IR
Measured Fan Flow=
Yes for both 1 and 2 is a Pass
O. 1, the undersigned, verify that the above diagnostic test resulrs and the work I performed associated with the tests) is ineonformance
with the requirernents for compliance credit: Me 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 ]
All
Tests , t t Date Insialling•Subcontractor (Co: Name) OR
PerromKd General Contract or.(Co. Name),
COMM Building:Department
HERS Provider (if'applicable)„
Building Owner at Occupancy
Compliance Forms August2001• A-25
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