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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptrt! 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
Date 4- 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). / - 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:
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
pefmit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(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 provisionsiof Section 3700 of the Labor
Code, I shall forthwith comply lwith" those provisions.
Date: i �s : _. .. Applicant .. ;
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 t D
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employee
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectidn purposes.
Signature (Owner/Agent) ��- i� ���• Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
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APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN &NEER
&11 a2W AVIV UE 62
Al-2f?Il AVEIAM 62
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USE OFFPERMIT
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CITY OF LA QUINTA
FINANCE DEPT.
RECEIPTDATE{
BY
PATE7N; 4DZ
INSP CTOR
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
PA
Drywall - Int. Lath
Final
Final a
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
j, -p`/
Appliances
Final
Final Zrz
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: .
-
APR -02-2004 FRI 11;45 AM WESTPAC AIR COND FAX NO, 909 739 9509
Installation Certificate: Residential CF -6R
Site Address PEI1wI11 11
60-367 Desert Shodw Drive Of 8 2-
1. HUTI DM INFORMATION
Shefi lloines -Trilogy - LaQuinla
60311 Trilo'•y Pkwy
La Quit'ita, CA 92253-1642
SLJi3DIVISION: Trilogy t«>, La Quinti
CITY: La Qtunta
COUNTY: Riverside
INSTAT,I,ING CONTRACTOR: WEST PAC AIIR CONDITIONING
2. PROJECT INFORMATION
11EATING UNIT
pS1'R1tii11-1ON
DIMTORPIPINCYR-
--- —
'1 Yl�i,
VALUR
Dlcxible. Thtctwork
Flexible Ductwork
in Atlic and
Will have a R -Value
11;nweert Floors
of 4.2 or Better
P. 02
T, ilie undcr,igncd, verify that the cquipmvnt listed in the category above my signature is the actual equipment
installed oral chat the equipment meet~ or exceeds the requirements of the Appliance Efficiency Standards. In
addition, Maw verified that tyre equipment is equivalent to or more efficient than the equipment specified on the
Cor lificate of Compliance submitted to demonstrate compliance with the Energy i✓:fficiency Standards for
rvsidendnl buildings.
3. HFATING INF01 MA.TiON
11EA'I'ING
MANUFACT
11EATING UNIT
AM'UAL 1J1+F.
HEATING EQUIP
l IEATING
1?Q1.J1P,
MAKE
MOGUL #
AFUE
CAPACITY
LOAD
Furoarc
Lennox
G1401TI-1-48B-0.90X80
4
88000
80%
4. COOLING INFORMATION
COOLING
MANUFAC'T
COMPRESSOR
ACTUAL EFF.
COALING EQUIP
COOLING
EQUIP.
MARE
MODEL #
SFFR
CAPACITY
LOAD
AIC Lennox 13ACC-048 12
The building design heat loss and design heat gain rate have been determined using a method specified in Section
150(h) of the Energy lit'licieney Standards, and are two of the criteria used for equipment sizing and selection.
6:l'1wtkivlOS"rATfc ir,XPANSION VALVE (TXV):
'I'hcTmostalic Expansion. Valve (or Conrntision approved equivalent) is installed and access is provided foe inspection.
Yes ( I No I I NIA
6. SUUMI'TTE'l) BY
ct..m U. -X CJ.%•i-�4A-O, DATE: .� 4-- -L
Signature installing HVAC Contractor
m
