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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
ChnIpter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
LRense # t Lic. Class P. Date
� .f 13 �� 61:i� /its
Date 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
...
pe felt Is issued. My workers' compensation insurance carrier &policy no. are:
Omer
NATIONAL UNION Policy No. 7145233
(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 foriwhich this permit is issued,
I shall not employ any person in any -manner sclas to become subject to the
workers' compensation laws of Qalifomiaf and agrfee that if I should become
subject to the workers' comp satpon r rovisionsl'of Section 3700 of the Labor
Codes a�foth comt ly with those provis ones.
Date" ✓ App�licantt
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. -
II -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 employees.
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 CityA nd State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property`for inspection purposes.
Signature (Owner/Agent), -'"A -^°- Date`"-��•� E
"
0000eI(,
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Q+�iE�D TRACT
%i �!f r[1 ��.�il.«71i.l.C► 9D 3t1C32S
JOB SITE
ADDRESS
APN
GSA- 41 DX+.SERT SHADOWS' DDM
OWNER
CONTRACTOR/DESIGNER/EN INEER
K -I& .LA Q-LWrA1,,1.x:
%r2A Lfi. QUWT,ALLC
81160 AVE -NUR 62
81260 AV :NMi 62
LAq.JDTrA, CA 92253
L AQDWA CA 92253
(76PX177-6005 MLO 'SBD
USE OF PERMIT
ICTx Pf:SkIli..s" DWE LNC
SE*1� .1,.C?T 90, P1,AW 350511. PE.iIttAI l' IlLt&S NOT INCLUDE, POOL., SPA,
BLOCK WAUA OR DRIj7'fif1VAY.AltiPROA4".H.
CUSTOM CONSTRUCTION 1,31,00 8P
PC IRC,HlP.AT10 531.04 SF
0ARA.G1-KAktl'ORT 330,00 Sl;
ES.1"£o'�W011) COSIT Or CG?�"" OMWC 17.01
16112?620
.{TILU& . 1 i1E KLI IMARY
CONSTRUCTION FRE? 101.000.418.000 $836.50
FLAN CHECK I14sE 101-000439-318 $632.2s
IIECHA141C L RE 101.000-42.1-000 526:;9"3
2LEG:'TIL'CAL PEP, 101-000-420-000 $IO2.79
PLY, I 1aIN G FFR 10 i -000-619a000 $1.2.4.00
STI :.E7ltiifiR°u TION FEE.I=FNID 101-t)f?0-2 .i-Clt?Li $16.13
GRADINO FRE 101-4000-423-000 W106
i)EVZLDPER191PACT FEP s��o5.oa
� - . IAC ' :.. 11 CIrION .�J+317 Z X i'".I°3ECK
UO3 I'' PALD 3. RE62
D
$0.00
`
r f
MAR 2 4 2004•xO , P»M >_7XS D3 E INOW
CITY OF LA Qli;NTA
FItA tdCE DEPT.
RECEIPT
DATE,
BY
N ED
11AJ;
INS$ECTQ$�
/YJ_
/ I 6
I pi `a e. 6.
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 .14_
Drywall - Int. Lath 09
Final
Final
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 ej PPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral AaPool
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
6--! ' i Installation Certificate: Residential CF -6R
Site Address
60-631 Desert Shadows Drive
1. BUILDER INFORMATION
Shea Homes - Trilogy - LaQuinta
60311 Trilogy Pkwy
La Quinta, CA 92253-7642
INSTALLING CONTRACTOR:
2. PROJECT INFORMATION
DISTRIBUTION
TYPE
Flexible Ductwork
in Attic and
Between Floors
DUCT OR PIPING R -
VALUE
Flexible Ductwork
Will have a R -Value
of 4.2 or Better
PERMIT #
SUBDIVISION: Trilogy @ La Quinta
CITY: La Quinta
COUNTY: Riverside
WEST PAC AIR CONDITIONING
M
I, the undersigned, verify that the equipment listed in the category above my signature is the actual equipment
installed and that the equipment meets or exceeds the requirements of the Appliance Efficiency Standards. In
Addition, Ihave verified that the equipment is equivalent to or more efficient than the equipment specified on the
Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards for
residential buildings.
3. HEATING INFORMATION
HEATING MANUFACT HEATING UNIT ACTUAL EFF. HEATING EQUIP HEATING
EQUIP. MAKE MODEL # AFUE CAPACITY LOAD
Furnace Lennox 80UHG4/5X-100 80% 100000
80%
4. COOLING INFORMATION
COOLING
EQUIP.
A/C
MANUFACT COMPRESSOR ACTUAL EFF. COOLING EQUIP COOLING
MAKE MODEL # SEER CAPACITY LOAD
Lennox 13ACC-060 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 Efficiency Standards, and are two of the criteria used for equipment sizing and selection.
&THERMOSTATIC EXPANSION VALVE (TXV):
Thermostatic Expansion Valve (or Commision approved equivalent) is installed and access is provided for inspection.
Yes ❑ No ❑ N/A ❑
6. SUBMITTED BY
DATE: 5
Signature Installing HVAC Contractor