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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
69064.5 B MC A 6130/04
Date G'a 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.
() 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 Policy No.
STATE FUND' E 30:s4'Od-fl2
(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 4ose pTovisions.
Date: fj` i C/- Cl"k Applicant—
f,.
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 e • o, ees.
2. Any permit issued as a result of this application becomes nulla Y Did if ,
work is not commenced within 180 days from date of issuanc of such
permit, or cessation of work for 180 days will subject permit to ca � II tion.p�
I certify that I have read this application and state that the above info at on is N�
correct. I agree to comply with all City, and State laws relating to th b Idin
construction, and hereby authorize representatives of this City to a ter upoDITy
the above-mentioned property inspection purposes. FIR
I Signature (Owner/Agent) e• Date /!'/9'C`l
BUILDING -PERMIT - PERMIT#
DATE VALUATION LOT 031st -14'7 TRACT
J
JOB'SITE -
APN
ADDRESS
79-900 TIS SMA BOY,
• --
OWNER
CONTRACTOR/DESIGNER/EN (NEER
WT He'J'tu J 1.0
..
143T 114 VESrMh-M, INC..
I`O BOX 810
1425 F: IDUV :IZ:Si`T3I DkZIM5
LA Q•i1URA CA 92253
PHORN . AZ 95034
002,257.1656 G'BT,4 4910
USE OF PERMIT
POOL ANDIOR SPA
POCA, SPA. .ALARM. WBARt.fi'. ERS SHA1.d,, B.9 YN PI -ACE AT PR&PLASTHR
1148F E-C'lION, EQUIPMENT ENCLOSURENOT INCLUDED
POOL A'NDIOR SPA 15000.00 1.Z
EfiS_r 'E1 MAW OF (110FIFER IJP 7 7.011IN
15,000.00
PLANC'fT1;t:l .Fr 101.000�n39-318 �1tk5,:IG
COrJw"i"Rt3 TION YEfr '101-000-41£f-00() $162.00
MECHANICAL RE — POOL 101-000.421.000 .524.00
E.1.K"FRICAL FW — POOL 101-000-420-000 $43.00
gI.EIMBDIO ME - POOL 101.000.419.000 $27.00
SUB-TOT.t L CONS°Tlr UC'110N' Aim PL" at -WK
I:.:M PRF-r-AMFEES
$0.00
TOT -A], PERIM FFF. S DAM NOW
&.`401130
V 19 2003 't` .
DATE t
BY
DAT FINALEDINSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
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
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
— %I
Waste' Lines
Heater Final
WaterTiping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
'Sewer Connection
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
` ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. :
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
INSTALLATION CER*T'-` JCATE (page 3 oi,•
.r►rnt► ► r4.' B I O S 71-906 b el. S o A S& I
�-' Site Address Permit Number
;,L7.00T LEAKAGE AND DESIGN DIAGNOSTICS
I.:
_fig DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM @ 25 PA)
Test Leakage (CFM) 1Lq
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
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) _
Pass if leakage fraction 5 0.06
❑ For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL: -
❑'Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes 0 No ❑ Visual Inspection of Duct Connections
CF -6R
Pass Fail
❑ ❑
Pass Fail
( THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ❑
Yes is a pass
❑ DUCT DESIGN
1 ❑ Yes ❑ No ACCA Manual D Design calculations have been
completed, Duct Design is on the plans and duct installation
matches plans.
2• ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
Pass Fail
❑ ❑
Pass Fail
❑ 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 H ERS provider a copy of the CF -6R
signed by the builder employees or sub -contractors certifying that diagnostic esting and installation meet the requirements
for compliance credit.]
_.fo 4 14
Tests i u e, ate 1 ng ubc ntractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
INSTALLATION CERTI VICATE (Page 3 of 13) CF -6R
Site.Address Permit Number
1kCT LEAKAGE AND DESIGN DIAGNOSTICS
W DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM @ 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
.Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) =
Pass if leakage fraction s 0.06 0 []
Pass 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:
❑. Yes , ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections ❑ ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV)
Yes 13No Thermostatic Expansion Valve is installed and Access is 01 .
provided for inspection
.�_.. Yes is a pass 'Pass Fail
❑ DUCT DESIGN
I ❑ Yes ❑ No ACCA Manual D Design calculations have been
completed, Duct Design is on the plans and duct installation
matches plans.
2• ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -I R.
Measured Fan Flow =
Yes for both I and 2 is a Pass
13 ❑
Pass Fail
❑ 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 -6R.
signed by the builder employees or sub -contractors certifying that diagnostic testing and installation meet the requirements
for compliance credit.]
f
TestsStg re, Date ris allin Subcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
' TALEATION CERTIEFICA.TE (Page 3 of 13) CF -6R
w- 0.0
SI a Address Permit Number
DUCT•EAKAGE AND DESIGN DIAGNOSTICS
'.DUCI,_LEAKA,(3Z 1ZN;DlJ('1`i()IV
Pressurization Test Results•(CFM Q 25 PA) Test Leakage (CFM)
Fan -Flow
If Fan Flow is Calculated as 400 cfmfton X number of tons,or 4s.21'.7 x Heating Capacity
In Thousands of•Btu/hr, enter calculated value hate
If fan flow is measured, enter measured value here
Leakage Fraction -Test L,oakagq(Measured or Calculated Fan Flow) a te_ 0
Pass if leak4ge fraction <'0.06 Pass . Fall
C3 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 . t Pressure pan test.or Hoose pressurization. test. '
O Yes O No U Visual Inspection of Duct Connections 0 0
Pass Fall
THERMOSTATIC EXPANSION*VALVE (TXW
6'Yes O No Thermostatic -Expansion Valve is installed and Access is -provided. for. inspection
Yes'is a pass "47. °
O DUCT DESIGN Pass Fall
ACCA Manual D Design calculations have been
1. U Yes Cl No completed, Duct Design (son the plan's and duct installation
matches plans..
2. O Yes O No TXV is installed or Fan ftow has been verified. If no TXV, 0 0
verified fan flow matches design from CF -IR Pass Fall
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
O 1, the undersigned, verity that the above diagnostic test results and the work I performed associated with tke test(s) is in conrommce
with the requirements for compliance credit. jibe 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 iequirements for compliance credit. l
Date i re,
Insta
Tats lling SP(Co. Name) OR
Performed - General Contractor(Co.Name)
COPY -ft - Building Department
`
HERS, Provider (if applicable)
Building Owner at Occupancy
AiLdLialivil klil-Ki"ItIalE (Page 3of13)
DUCTUAKAGE AND DESIGN DIAGNOSTICS
AD—UCFLEAJKAG.9 REDUCTION
CF -6R
Pressurindon Teit Results (CFM @ 25 PA) test Leakage (CFM)"
Fan -Flow
If Fan Flow Is Calculated as 400 cfni/ton X number of tons, or 4s 21*3 x Heating Capacity
In Thousands d-Blulhr, enter calculated value hbre
It fih.flow Is measured, enter measured value- here_*
Leakage Fraction Test Leakagq(Measured-or Calculated Fan Flow)
1P a
Pass if leak4ge fraction <0.06
Pass • Fall
0 For AEROSOL TYPE SEALANTS' ONLY -The'following diagnostic testing was completed:
Duct Fan Presiuriza6on at rough -in measured -leakage (CFM)
CHECK AFTER FINISHING WALL:
b'Yes :O Nd 0*'Pressure pan te"st.o*r House pressurization- test.
0 Yes 0 No .0- Visual Inspection of Duct Connections
a 0
Pass Fall
!THERMOSTATIC ATIC EXPANSIONYALVY(M
PVes O.No Thermostatic -Expansion Valve' is installed aAd Access is -provided. for inspection
. yes'is a pass
Pass Fall
0 D UC`r DESTgN
ACCA Manual D Design calculations have been
T. 13 Yes O No completed, Duct Design is on the plan's and duct installation
matches plans.,
2. ClYes (3No 7XV Is Installed or Fan flow'has been verifled. If no TXV, 0 (3Pass Fall
verified fan flow matches design from CF -IR
Measured Fan Flow
'Yes for both I and 2 is a'Pass
0 1, the undersigned, verify that 'the above diagnostic test resuld and the workI performed associated with the test(s) is in conformancewith the requirements for compliance credit. fThe builder shall provide the HERS S provider ' a copy of the CF -6R signed by the builder
employees or sub -contractors certifying that diagnosticAgsting and Installation meet the *uirements for compliance credit. j
Sts tum, Date7tlling bcontmctor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY -ft 'Building Department
HERS Provider Provid' (it applicable]
Building Owner at Occupancy