0309-339 (SFD)LICENSED CONTRACTOR DECLARATION
In I. I hereFjy affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Profeci3ionals Code, and my License is in full force and effect.
O =)M License # Lic. Class Exp. Date
r-- Cisr- LLJ
fjl f
3 111104
. 7 ^7Yi•^•
Z r --Date i : -.t 7?' ( * Signature of Cot actor --�
(Do r7.r
J U C) OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z ( ) 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).
C'`) () I am exempt under Section , B&P.C. for this reason
L
N Date Signature of Owner
ON
0)U Q 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.
WAT20NIAL UMON VK 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' compensation provisions of Section 3700 of the Labor
Code,.l,sh_all fort6ith comply with those provisions.
Date• r '�d . L— Woplicant t • x �'•• �` C. '
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 &'eac
whose request and for whose benefit work is performed under or ant to
any permit issued as a result of this applicaton agrees to, & shall,
& hold harmless the City of La Quinta, its officers, agents and a yees.
2. Any permit issued as a result of this application becomes null Did 0C,
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 cel
I certify that I have read this application and state,that the above info mation sITM
correct. I agree to comply with all City, and State laws relating to th
construction, and hereby authorize representatives 6f this City to enter upon
th(above-mentoned:property for ins�ectionapu•,rposes. 4
•/' Sig natur?Owner/Agent) �. �'°• M a "" Date"`
BUILDING PERMIT PERMIT-
—
DATEVALUATION LOT '-� TRACT
1 �
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JOB SITE
APN
ADDRESS
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.OWNER
CONTRACTOR / DESIGNER / EN (NEER
V. FA MI'An
I'le-YMEJ
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81 1260 uhiMCiF 6t
Lk'a, QUINTAa CA 4/.2883
LA < ''ti`61I4 T -Al CA 81983
_
UDLP 6.876
USE OF PERMIT
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$3,31{}9.64
2 3 2003
STA, -VITM �•F� W DAM':N��W
OF LA QUINTA
ANCE DEPT.
RECEIPT
DATE
BY V i'
DAT ALE
INS
R
INSPECTION RtCOIRD
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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
_
POOLS - SPAS
BLOCKWAL
PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVAL
ry
Gas Test .
Electric Final
Waste Lines
Heater Final. .,
Water Piping
Plumbing Ficial.
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures µ.
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors 110,
Temp. Use of Power
Final
Utility Notice (Perm)
APR -02-2004 FRI 11:46 AM WESTPAC AIR COND FAX NO. 909 739 9509
Installation Certificate: Residential CF -611
Site Address Lo fS'!:5'
60-323 Desert Shadow Drive
1.BIJI LDLItINFORMATJON
Shea ITomes - Trilogy - LaQuinta
60311 Ti ilo,gy Pkwy
La Quiula. (:A 92253-76,42
INSTALLING CON1'RACTI'OR:
2, T'IZO.l1 '(:'I` INIPOItibiA'I'ION
)IS. RIBI TION
I'YP R. .
Flexible Ductwork
in Attic and
Botwecu Flours
DUC T OR PIPING R-
_VAr_m
Flexible Ductwork
Will have a R -Value
of 4.2 or Better
PERMIT #
SUBDIVISION: Trilogy (a), La Quinla
CITY: La Quinta
COUNTY; Riverside
WEST YAC: ATR CONDITIONING
P. 04
I, the undorsiVned, verify that the equipment listed bn the category above my signature is the actual c:(luipnxnt
installed ;mild that the eLluipinent rucets or exceeds the regnircments of the Appliance Effiiciency Standards. In
addition, (licnvo verikkI that the equilunent is equivalent to or more erriicicnt than the equipment specified on the
Corlificatc of Compliance suhmilleil to demonstrate compliance with the Energy Efficiency Standards for
residential buildings.
3. 1111rr.A'f INC, INFOR1V ATTON
1iPA'I'1NG MANUFACT IWATiNGUNIT AC:TUA1. EFF. HEATING EQUIP ITHATING
1:Q[11l', MAKE MODF.Lit - AFUE, CAPACITY LCAT)
pomace Lennox G40UII-4813-090X 80% 88000
800,
4. C00T,1NG INFORMATION
C001ING MANIIFAC:T COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
],,QlJ1P. MAKI? MODEL # SBEI-R CAPACITY THAT)
A/C Laimox 13ACC-048 12
The building design heat loss and design heat gain rate. have been determined using a method specified in Seclion
150(h) of the Energy Efficiency Standards, and are two of the criteria used for equipment sizing and selection.
6.111ERMOSTATIC EXPANSION VALVE ('1XV):
Thermostatic 13xpansiwn Valve (or Conmmision approved equivalent) is installed and access is provided for inspection.
Yes I..L-e No i. . ) N/A I I
6. SI, B"11Cf1;1) BY
-.._ Lt„ p.�,tt $� DATE: 4
Signawre installing I1VAC Contractor