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LICENSED CONTRACTOR DECLARATION
1r�pter
eby affirm under penalty of perjury that I am licensed under provisions of
9 (commencing with Section 7000) of Division 3 of the Business and
ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
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1/31104
5
tte; -� � Signature of Contractor
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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 properly, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &' Professionals
Code). r
() 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.
i' ATIONMI UNION 1j: ?634'1'
(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' compe�nsationprovsions. of Section 3700 of the Labor
Code I shall,forthwith comp) ,With those provisions../ .-.--..,,.;.......
Date: 4.i �r �.%��•- Applicant•--~''
Warning: Failure to secure WorkersCompensation 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
whose request and for whose benefit work is performed under or p nit to
any permit issued as a result of this applicaton agrees to, & shall,,, nify
& hold harmless the City of La Quinta, its officers, agents and er ees.
2. Any permit issued as a result of this application becomes null a id HOC
work is not commenced within 180 days from date of issuanc( of uch
permit, or cessation of work for 180 days will subject permit to car ell ' .—
I certify that I have read this application and state that the above info ation is FII
correct. I agree to comply with all City, and State laws relating tc the building
construction, and hereby auth/orize representatives of this City to enter upon
the above-mentioned property four 'Inspection purposes.
f/Sign ature•-(Owner/A'gelit) Date IC) 11 ¢
BUILDING PERMIT PERMIT#s
DATE VALUATION LOT Z`};arj-1I TRACT
JOB SITE
APN
ADDRESS
t, • a 4-.1YEfs'�k ME Mffit D 0, W8 l RYVE
74"430-0 17
OWNER
CONTRACTOR/DESIGNER/EN INEER
81; 260 A4NI?1 , 62
460 ANTIIINVE .62
X,,A QM1 EA, CA 92883
LA QY1{.i rA CA 402883
MAI 6V6
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USE OF PERMIT _
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:'14TJIf�'t� IU i'10� A?,E 101-.000-4) 8x000 IM6.40
PLAN (:: PICK: I'EE 10 j -Cl00-430-31 L•
�ijb;C�Xt�',IC 1, 1r 101-000-4 1^00' 573.35
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2 3 2003
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OF 1A QUINTA
NCE DEPT.
RECEIPT
DATEBY
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DATE F,Iy�a D
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INSP TOfI�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
VReturn
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
BLOCKWAL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVAL
Gas Test
Electric Final
Waste Lines
I I X
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 cfyl6
Utility Notice (Perm) L/49
COMMENTS:
5
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INSULATION CE=RTIFICATE
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This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24; State of California, in the building located at
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60-284 DESERT SHADOWS.DRIVE LOT 3, LA QUINTA CA
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CEILINGS:
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TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
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WALLS:
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TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-13
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GENERAL CONTRACTOR: SHEA HOMES LICENSE #
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BY: TITLE:
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517
BY: ATITLE: ACCOUNT REPRESENTIVE DATE: 7
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APR -02-2004 FRI 11:48 AM WESTPAC AIR COND FAX NO, 909 739 9509 P. 01/24
histallotion Certificate: Residential CF -6R
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,Site Address Lp 7 4-- 3 PERMIT?Y
60-28.1 Desut Shailow Drive
I,131111,103Z INFORMATION SUBDIVISION: Trilogy (n? Ia Quin(a
Shy a homes -Trilogy - I.aQuinta CiTY: Ta Quinta
60311 Trilogy Pkwy C:OUNI Y: Riverside
La QL1inta, C.A 92253-7642
INSTALi,1NCT CONTRACTOR,
2.1'1Z0JECT INFORMATION
I)IS.IRIBU_1ION
Flexible Ductwork
- in Attic and
Between Floors
DU('f OR P1P1Nc Tt-_
VAT_i TI?
Flexible Duclwork
Will have.a R -Valu.:
o174.2 or Better
WEST PAC AIR C.'ONDITiONING,
1, (Ile undcmigned, verify that the equipment listed in the category above my signature is the actual equipment
insiallril and th.AT the equipment meek or exceeds the requirements of the Appliance Eff icicncy Standards. In
addition, Ihave verilied that the oquipmew is equivalent to or more efficient than the equipment specified on the
Cerlillcale (if Compliance submitted to demonstrate compliance with the Energy Efficiency Standmis for
repidenii-A buildings,
3, I1E ATINOT INIS OltHATION
I iHATING MANUI ACf HEATING, UNIT ACTUAL 1s17F, IILATING EQUiP I[EATING
EQmP, MAKE MODET, it AF LIE CAPACITY I,OAi)
i'*ntnace T.cnno r G40111-1-4913-09OX 80% 88000
80%
.4. COOT-ING. INFORMATiON
COOLING MARIUFACC COM11RESSOR ACFIJAL EFF.' COOLING LQU1P COOLING
EQUIP. MAKE MODL.I, it SLER CAPACITY LOAD
A/C I,.enno c 13ACC-048 12 _._ .... .
The hnilding desiga Beat loss and design heat gain rate have been determined using a method specified in Section
150(h) of Ilia Energy Efficiency St uulards, and are twu of the criteria used for equipment sizing and selection.
h.'l UERMOSTATIC: EXPANSION VALVE (TXV):
'I'hcrmoslatie Eizpallsion Valve (or Colujtrision approved cgrnivalent) is installed and access is provided for inspection.
Yes �No ( ( N/A [''.1
6. 181AIMIT fT,D i V ,
Signature Installing TIVAC Contractor