0401-109 (SFD)M
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 and
Prof4ssionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6590645 B WC: A , 6le"/04
Date f '/ '� ' 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.
()J 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 STATE M -ND Policy No. 15113006-01
(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. f-•1
Date: r Applicant 2 Vi /, rw�
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 enter upon
the above-mentioned property for,inspection purposes. �.
Signature (Owner/Agent) "
o/
BUILDING PERMIT PERMIT# `
DATE VALUATION LOTTRACT
4/ 1.79 %,150' 15 29854td2
JOB SITE ,_•. • APN
ADDRESS 51'--<,it.A3 VU AV. AYYrE 7724604W
W
OWNER CONTRACTOR / DESIGNER / EN (NEER
PO DOX 61.0 1425 X t71M'�ff BITY DRWBI
LAQUINTA CA 92253 PHO1v IX A7 85034
(602)257.1656 CElh 4990
USE OF PERMIT
SFA - LOT 15, P1,,AW PIA. PERMIT DO&S''NOT INCLUDE P001, SPAT,
BLOCK WALL% OR DRIVEWAY -APPROACH
TACT CONST.RUCTIM) 2,094.00 3
PORCH/PATIO
997.00 Sr
G A.RAC}F./CA1' PORT
447,00 S>'
ITIN i YV1:A.UD COM'OF C01MMUC120N
179,36I Z9
1y'rUM 11'1 £ ul7 ' li 'Y.
CONSTRUCTION FES:
101-,000.418.000
$419,50
P€.AV CHECK FEE
101-000-439-•318
$775.68
MEC!'l./i;IvlCAL FEE.
101-000-421-000
MIN
CLfp,C' 4CALIME
101-000-4.20-000
V0.43
PLUMBING F'i?E
101.0,00.419.000
$200,00
39"It0NO MAOTION FLEE - RES11)
101-140-241-000
$17.94
ORA alit o MLS
101=000-423-000
SUN
DEVELA)PEI? IMPACT ; ,PE
$a 001.00
�:a'iXi3�.O'T , i."C9_NRnITC17C71~1' .PST% 2LA!"T 0- CK 34,202.05
A\ ! f .IMS J?�-P M F= $0.00
JAN 2 8 2004
CITY OF LA Ql OTCA
RECEIPT DACE � �J BY DA�INALED` � INSPECT$E;�
.i
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
-Z _
F.A.U.
Framing
S -.2 —
Compressor
Insulation
— G
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
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
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: li.Az.Z
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TES"ICING (Page.I of 7) CF -4R
PALMILLA PH -6-
Project Title
50TH & JEFFERSON
Project Address DARRELL MORGAN 760-275=8230
Builder Contact Telep1tone
RICHARD KROWN 760-250-1852
HERS Rater Telephone
09-14-04
Date
R J T BUILDERS _ _
Builder Name
.ACACIA P-2 3 UNITS
Plan Number �-
GROUP 4
_ #CCNRK613292 09-14-04 LOT # 15
Certifying Signature Date Sample House Number
DESERT ENERGY SERVICES CHEERS
Ei.rm: HERS Provider:
Street Address:P O. BO_X 621 RANCHO MIRAGE.CA. 92270CitvState/Zip:
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 installer has provided a copy of CF -611 (Installation.Certificate.
El Distribution system is fully ducted (i.e., does not use building cavities as plenums or platform:returns in.aieu of ducts)
❑ Where cloth backed. rubber adhesive duct to a is installed, mastic and drawbands are used in combination- wiih.cloth
backed. rubber adhe'sivc:duct tape to scal.leak-s at.duct. connections-
❑� MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Duct Pressurization Test Results (CFM (L25 Pa)
Test Leakage Flow in CFM
If fan flow is calculated as 400cfnt/ton z number.of tons enter calculated
value here
If fan flow is measured enter measured value here
Leakage Percentage (1 00 x Test Leakage/Fan Flow) _
Check Box for Pass or Fail (Pass=6% or less)
,❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑ No Thermostatic Expansion Valve is.inslalled and•Access is
provided for inspection
Yes is a pass
Measured
values
❑ ❑
Pass Fail
Pass Fail
INSTALLATION: Cf _ I'IFLCATE: (Page:3 of ` CF -6R
Si a 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 00 cfrrJton x number of tons, oras 21.7 x Hearing 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)
•Pass if leakage fraction < 0.06 Pass Fail
O'For AEROSOL TYPE SEALANTS ONLY -Thefollowing:diagnostic testing tvas.completed:..
Duct Fan Pressurization at rough -in measured leakage :(CF l .
CHECK AFTER FINISHING WALL:
O Yes O •Noy Oi Pressure. pan test or House pressurization test
O Yes O No. O Visual, Inspection of:Duct Connections o 0
Pass Fail
THEMM0STATIC-EXPANSION VALVE (TXN
IT`Yes. O No Thermostatic.Expansion, Valve is installed and Access is - provided -for inspection
Yes.is a pass
O DUCT DESIGN Pass Fail .
ACCA-Manual D_Designcalculations have been .
.1. ❑ Yes O. No completed; Duct Design is on•the plans and, duct'installation
matches plans.
0 El
2. O Yes O No .TXV is installed or Fair flow has been verified. If no TXV,
verified fan Cow matches design from CF -IR. Pass Fail
Measured Fan Flow=
Yes for both 1and 2 is a Pass
O.' 1, 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 1
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. J
i
X6
Tests Signa re, Date Installing Subcontractor (Co. Name) OR #((
Performed General Contractor: (Co. Name). i
COPY TO: Huilding epararxn D ti
HERS Provider (if applicable) }
Building Ouner'at Occupancy'
S
Compliance Fortes August 2001 A=25
„ t
• �1
b
P1 TSTALI�ATIO� "Cif- f IFICATE (rade 3 of
CF-6R
�,,�,� „� ��s �- � s vim• �
-
Site Address permit Number
DUCT L' EAKAGE- AI\\DDESIGN DIAGNOSTICS
llUL1''LEAKAGE REllU TION
Pressurization Test Results'(CFNI ®25 PA) Test Leakage,(CFM)j�pa
Fan Flow
If Fan Flow is Calculated as 400 cf ntton x number of tons, ora 21.7 x Heating Capacity
in Thousands of BtuJhr• enter calculated value here
- If fan flow is measured, entermeasured value here
Leakage Fraction Test Leakage/(Measured or Calculated Fan Flow) =
o
Pass ifleakitge fraction <0.06 Pass
Fail
C For: AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed:
Duct Fan P.ressurizationat rough-in measured leakage (CFM)
CHECK AFTERFNISHING WALL: .
❑ Yes ❑ No ❑ P•ressure.pan test or. House pressurization test
b Yes ❑:No O, Visual.inspection of.Duc( Connections o
0
Pass
Fail
TAE]IML OSTATIC EXPANSION VALVE -
'
P*Yes- ❑ No Thermostatic. Expansion.Valve,is installed and Access is.- provided for inspection
Yes is'a pass
-Pa;ss
Fail
❑ DUCT DESIGN
ACCA•Manual D' Design calculations have been
1. ❑ Yes, ❑•No completed; DucttDesign is-on the plans-and duct installation
matches plans:
2. • ❑ Yes ❑ No TXV is installed or Fari flow has been verified. If no TXV, D
o
Fail
verified fan flow matches design from CF-IR. 1'x55
Measured Fan Flow=
+
Yes for both le and 2i a Pass
i
❑ I, the undersigned; verify that -the above diagnostie.testresults and the work I perforated associated with -the test(s) is in conformance
#
with the-requirements for compliance credit. [The builder'shall provide the HERS provider 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 1
�i
A/i d
Tests ignatu ; Date' Installing Subcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY.TO: Building .Dc drftent
HERS Provider '(if' applicable)
Building Owner at Occupancy.
0
���.-..•.� , : �. . IT,T l��.t f^,T�f1TTT/ti .♦ TT
3 of
CF -6R
Site Address rermtT Numoer
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT,LEAKAGE REDUCTION
7
Pressurization Test Results .(CFM ® 25 PA) Test_ L.eakage.(CFM)�-f
Fan Flow '
If Fan, Flow is Calculated as 400 cfrnrton x number of tons, oras 21.7 x Heating Capacity
in Thousands: of.Btuthr, enter calculated value here.
1f fan Ro%v is measured, enter measured value here
Leakage Fraction = Test Leakagel(Measured or Calculated Fan Flow)
Pass ifleakage fraction <•.0.06
Pass Fail,
❑ For,AEROSOL TYPE SEALANTS; ONLY -The follot►•ing diagnostictesting was completed:
Duct Fan Pressurization'at rough -in measured leakage -.(CFM)
CHECK AFTER FMSHNG WALL:,
❑,Yes ❑ No ❑ Pressure pan test or. House pressurization test
❑ Yes :❑No ,❑ Visual.Inspection of Duct Connections
.o 0
Pass Fail
Mw THERMOSTATIC EXPANSION VALVE.(TXV)
Yes- O.No 'Ihermostatic_Expansion Valve is -installed and Access is- provided for inspection
Yes isa,pass
Z O
Pass . Fail .
❑ DUCT DESIGN
kcckmanual D`Designcalculations have been
1. O Yes 0 No completed, Duct Design Is on the plans and dOct installation
matches plans. .
2. O Yes 0 TXV is installed or Fan (low 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
❑ I; the undersigned, Verify that the above diagnostic test results andAhe work I performed associated with'the tests) Win conformance
with the requirements -for .compliance crediL fnc: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
Tess Signature; Date Installing Subcontinctor (Co. Name) OR
Performed General Conuactor,(Co. Name')
COPY TO: Building Department
HERS Provider (if applicable)
Building O%%ner at Occupancy .
Compliance Forms August 2001 A-25
u