BMCH2014-1138LICENSED 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 Professions Code,
and my License is in full force and effect.
License Class: _ License No.: LIC -0005383,r
Daa rContractors/ C�r-Fcre_P A -le
1Cie
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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 provisions of the
Contractor's 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).:
(_) 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 an owner of property who builds or improves thereon, and who does the work
himself or herself 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.).
(_) I, 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.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
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 Nam
Lender's Addi
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 wokk for which this permit is issued.
-A 1 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 and policy number are:
Carrier: _ Policy Number: _
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
coomply with those provisions.
1� 1
Date: Applicant:
L/
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS i LAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN S UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COS OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official 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, and the applicant, each agrees to, and
shall defend, indemnify 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 cit o enter upon above•
mentioned property for inspection purposes.
Date' Signature (Applicant or Agent):' r//Jjz
.
78-495 CALLE TAMPICO T4t�p D 4 Qubtro
VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253
FAX (760) 777-7011
COMMUNITY DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 11/6/2014
Application Number: BMCH2O14-1138
Owner:
Property Address: 575401NTERLACHEN
JOSEPHINE NEWELL
APN: 762180021
Application Description: HVAC CHANGE OUT- (1) 3 TON 15SEER/80AFUE SYSTEM
Property Zoning:
�—�►
Application Valuation: $11,832.00
Q
�t
a
Applicant:
Contractor:
N
iti o w
EFFICIENT AIR CONDITIONING INC
EFFICIENT AIR CONDITIONING
IN S a
0 OUTSIDE CITY LIMITS0
OUTSIDE CITY LIMITS
d o
LA QUINTA, CA 92253
LA QUINTA, CA 92253
CD Q
Z
(760)343-5340
z
Llc. No.: :LIC -0005383
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 Professions Code,
and my License is in full force and effect.
License Class: _ License No.: LIC -0005383,r
Daa rContractors/ C�r-Fcre_P A -le
1Cie
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's 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 provisions of the
Contractor's 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).:
(_) 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 an owner of property who builds or improves thereon, and who does the work
himself or herself 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.).
(_) I, 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.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
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 Nam
Lender's Addi
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 wokk for which this permit is issued.
-A 1 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 and policy number are:
Carrier: _ Policy Number: _
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
coomply with those provisions.
1� 1
Date: Applicant:
L/
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS i LAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FIN S UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COS OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,
INTEREST, AND ATTORNEY'S FEES.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official 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, and the applicant, each agrees to, and
shall defend, indemnify 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 cit o enter upon above•
mentioned property for inspection purposes.
Date' Signature (Applicant or Agent):' r//Jjz
DESCRIPTION
FINANCIAL INFORMATION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
BSAS SB1473 FEE
101-0000-20306
0
$1.00
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
Total Paid forBUILDING STANDARDS ADMINISTRATION BSA
$1.00
$0.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
HVAC CHANGEOUT - PACKAGED UNIT
101-0000-42402
0
$36.26
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PAID
PAID DATE
HVAC CHANGEOUT - PACKAGED UNIT PC
101-0000-42600
0
$24.17
$0.00
PAID BY
METHOD
RECEIPT #
CHECK #
CLTD BY
Total Paid forCHANGEOUT:
TOTALS:•
$60.43
$0.00
•0
Description: HVAC CHANGE OUT - (1) 3 TON 15SEER/80AFUE SYSTEM
Type: MECHANICAL Subtype: Status: SUBMITTED
Applied: 11/6/2014 SKH
Approved:
Parcel No: 762180021 Site Address: 57540 INTERLACHEN LA QUINTA,CA 92253
Subdivision: TR 27332 SEE ASSESSOR MAP 761 PG 47 Block: Lot: 3
Issued:
& 48
Lot Sq Ft: 0 Building Sq Ft: 0 Zoning:
Finaled:
Valuation: $11,832.00 Occupancy Type: Construction Type:
Expired:
No. Buildings: 0 No. Stories: 0 No. Unites: 0
Details: HVAC CHANGE OUT - (1) 3 TON 15SEER/80AFUE SPLIT SYSTEM [2013 ENERGY] CARBON MONOXIDE ALARM(S) TO BE INSTALLED
PRIOR TO FINAL INSPECTION. 2013 CALIFORNIA BUILDING CODES.
REMOVED $91 CHARGE AS SECOND UNIT WAS REQUESTED ON APPLICATION AND MISSED BMCH2O14-1114 ALREADY ISSUED
CONDITIONS
DESCRIPTION I ACCOUNT I QTY I AMOUNT
PAID I PAID DATE I RECEIPT # I CHECK # I METHOD
BSAS SB1473 FEE 1 101-0000-20306 1 0 $1.00 $0.00
Total Paid forBUILDING STANDARDS ADMINISTRATION $1.00 $0.00
BSA:
PAID BY I CLTD
BY
Printed: Thursday, November 06, 2014 3:09:20 PM 1 of 2 Cg? SYSTEMS
VISO
' Permit Details PERMIT NUMBER
Cit of La Quinta BMCH2O14M-1i3!
, Y
DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD
BY
HVAC CHANGEOUT - 101-0000-42402 0 $36.26 $0.00
PACKAGED UNIT
HVAC CHANGEOUT - I 101-0000-42600I 0 I $24.17 I $0.00 I I I
PACKAGED UNIT PC
Total Paid forCHANGEOUT: $60.43 $0.00
INSPECTIONS
SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED
DATE DATE
RESULT REMARKS NOTES
MECHANICAL FINAL"
REVIEWS
REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED STATUS REMARKS NOTES
DATE
Printed: Thursday, November 06, 2014 3:09:20 PM 2 of 2
C9?LJ LJ SYSTEMS
Jov • 06 2014 02:31PM HP FaxEfficient Air 17603432707
page 2
Simplified Prescriptive Certificate of Compliance: 2008 ResidenjW H'VACAPerallons CF -IR -ALT -
Climate Zones 10 to 15
She Address:� � �� b I n � r 1 r't G h 8s1 Enfomenserrr Agency: Date: ] (�J Peradt M:
Conditioned Floorl
r'quTmcm Lost MNimum Etricien ' Duct insulation requirement Arca Thermostat
Packaged Unit
0 Furnace AFUE 1r ❑COP
Over 40 A of ducts added or Attack
replaced in unconditioned spas Served stern
D Indoor Coil SEl?1t ❑ HSPF _ by (%jnos ahrady
O Condensing Unit EER �Z-S� 0 Rcs6Unca OR 6 (CZ 10-13) sf prrAmm Must be
p Other 13 R g (CZ 14-15) 1KsW&4
1. Efulpmad Type: Choose the equipment being installed.• ifnrore than one systema, use another CF -1 R-ALT-HVACjor each rysrerm
2. AftnlnMM EgelpnreM E,ak*weler. 13 SEER 78% AFUR 7.7HSPF for typical residential syatenrs.
ITERS VERIFICATION SUMMARY Listed below ate four HVAC alteration Options. The Walla decides what work is being done and
picks one of the appropriate Options. Each Option lists the HERS mcasu s that must be conducted. A copy of the forms shell be left en site for final
inspection and a copy given to the homeowner. At final, the inspector verifies that the work listed on this form was in fact the worst completed by the
installer. The inspector also verifies that each appropriate CF -6R and registered CF -4R forms (no hand filled CF-4Rs allowed) arc filled out and
sizmcd. BVnning October 1. 2010, a retistered coPY of the CF -IR and CF -6R sball also be on site for final ins
1. HVAC Chaugeout Required Folios:
• All HVAC Equipment replaced CF -0R forms: MECH-04. MECH-2 l -HERS and (for split systems) MECH- 25 -HERS
CF4R fonts: MECH- 21 and for split stems MECH-25
• Condenser Coil and/or
• Indoor Coil and /or CF-611forms: MECH-2I -HERS and (for split systems) MECH- 25 -HERS
• Furnace CF -411 forms: MECH- 21 and (for split systems) MECH-23
For Split Systems: Duct leakage < 15 percent; RC, CCA > 300 CFM/ton(Minimum Air Flow Requirement), TMAH
For Packaged Units: Duct leakage < 15 percent
Exempted from duct lealmgc testing if:
13 1. Duct system was documented to have been previously sealed and confirmed through HERS verification, or
O 2. Duct systems with lest than 40 linear feet in unconditioned space, or
❑ 3. Existing duo systems are comsuuctad, insulated or sealed with asbestos
O 2. New HVAC System Required Form -5:
• Cut in or Changoout with new CF -0R forms: MECH-04. MECH-20 HERS.and (for split systems) MECH-22-HERS, and MCH -25 -HERS
ducts: (sl[ new ducting gpd all CF -4R forms: MECH 20-, and (for split systems)MECH-22, and MECH 25
new ui ent
For Split Systems: Duct leakage < 6 percent; RC, CCA> 350 CFM/ton, FWD, TMAH, SIMS, and either HSPP or PSPP.
For Packs Unks: Duct leakage < 6 perwnt
❑ 3. New Ducts with Re lacement Required Forms:
• Includes replacing or installing all new ducting CF -6R forms: MIECH-04, MECH-204HERS.and (ror split systems) MECH-25-HERS
and/or outdoor condensing unit wxuor indoor CF -4R forms: MECH-20 and (for split systems) MECH-25
coil and/or furnace Not all equipment changed.
For Split Systems: Duct leakage <6 percent. RC, CCA -2:300 CFM/ton, TMAH
For Packs ed Units: Duct leakaRe < 6 percent
O 4. New D itteft over 40 feet Required Forms:
a Includes adding or replacing more than 40 CF -611 forms: MECH-04, MECH-2I-HERS CF4R forms: MECH-21
linear feet of duct in unconditioned space. I
For split system or packaged units: Duct leakage < 15 percent
O EXCEPTION: Existing duct systems constructed,, insulated or soled with asbestos
Contractor (Documentation Author's /Responsible Designer's Declaration Stattment)
• 1 aYt ty that this Certificate of Complisrw documcridation is accurate end complete.
• I am eligible under Division 3 ofthe California Business and Professions Codc to rrcvept responsibility for doe design identifi cd on this Certifrau of Compliww.
• !certify that the ersergy features sad perfortautoe slrcxifrcatiats for the design identified on this Catifiate ofC liance conform to the
Pans I and 6 of the Califomia Code of Regulations. °� rr gttinenrents ofTitte 24,
• The design fcattt identified on this Certificate of
Coruptiarmc an cons with the inf ted on other applicWe compliance foram, workLkets,
cal AM M Plans and strocifrcuioas submined to the enforft-m ._.:�.�_ _..
a m . S 1f, t A,. Signature
cc tri �- t r G'bYY i �'(v .n I eau:
_Oct Z" inn p 20-(1 I S ! N
I License:
JZip� I q
Phoncrt; -h- 1?i 2
Bin. #
Qty of La Quinta
Building at Safety Division
P.O. Box 1504,78-495 Calle Tampico
La.Quinta, CA 92253 -:(760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
IW41
MGMI^4 t'4ffl
Project Address: �- 1
Owner's Name:
A. P. Number.
Address: J ��
Legal Description:
Contractor.
City, ST, Zip: G
'
Telephone — °. '�. . '
Address: �.
Project Description: ` d 1 S n
City, ST, Zip:
Telephon -(-� 5�36-
III . , ) o LX 5-1. icer
State Lic. #44 i _W_9 -
City Lia 9..
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone:
State Lia #:
Name of Contact Person
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.:
# Stories.
Funks:
Telephone # of Contact Person( _
Estimated Value of Project: fi 7J�
APPLICANT: DO NOT WRITE BELOW THIS LINE
H
Submittal
Req'd
Recd
TRACMG
PERMIT FEES -
Plan Sets
Pian Check submitted.
Item Amount
Strgctuhd Cafes.
Reviewed, ready for corrections
Plan Check Deposit. .
Truss Calcs.
Called Contact Person
Pian Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted.,.
Mecihariical
Giading plan
2'! Review, ready for correctionsirasue
Electrical
Subcoutactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN ((OUSE:-
'^' Review, ready for correctionsPkssue
Developer Impact Fee
Planning Approval
Called Contact Person
A.LP.P.
Pub. VAx. Appr
Date of permit issue
School Fees
Total Permit Fees