0402-125 (SFD)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
Prgf,?. sionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-777699 B4/30/04
Date -2 A a % Signature of Contractor r<� �----
r
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'SCOMPENSATION 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) 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.
:ADERT Al UTUAL Y ".-- VIA262DW72.1012TT.
(.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 those provis ons,.^
Date: 7— i�o r 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 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 City, and 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.)'/• Dated lG
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
2 ? t' M21 8-I .M i'7 :403 7
JOB SITE
APN
ADDRESS
5A)--805 Fm viopm-oonrave
77-2.50-01.1
OWNER
CONTRACTOR/r. ER
TOLL BROTt°i -: S IWO
'5OLL l s:l2G"!,' ML13 INC
73.121 FRED NVA- Ll` G 0100
73-121 FRED W lA�T0 M 00
PA:Ud MnRT CA 92260
PALbA DEIMR.z CA. 92260
060)674-9699 CBL0 3832
USE OF PERMIT
Gr_RPANA7,YIiMM4
:AFD - JX)T 176, MIR.AMONTF-B. 1►11. MI T 1?OFS NOT 19CLUDIZ SLOC'IC
WALLA, POOL„ SPA OR Dl"UVRIWAYAPPROACH
CUSTOM CONSTRUCTION 3,847.0 SF
PORCH/PATIO 563.00 SF
0WIRAMCARPORT i62.6{181`
FSI:'133r1<d4 'FD core OF C631VSIRT1'G911'1t7H
-421,831mo
CONSTRUCTION 1±"e,1. M-000-4181-000 51,.40.36
11,LAN CHECK FEE 101-000-439-318 $1,149.22
MECHANICAL FEE 101.000.4.2.1-000 s15d),00
E11ECTRICAL FEE 101.000-420-4100 $206.69
PLUME4140 FEE 101.000-4419-000 919DIDD
STIRON0 MOTION InE - RESID 101-000-14.1-000 $32.19
(RAWNG FEE 101-000-42.1-000 50100
DRVLI.OP9R.IMPACT PD.' $2,405.00
,SRT IIA PUBLIC` PLAC S - W SIC 2•.70.000-445.000 $304.70
"`1+I t13C IIQ 11.1M PTIM C1111ECK
$5.868,30
Fx�� 3 1004 4x M ��> �:�S Dom: NOW
&5,868_,0
CITE' OF LA QUiNTsA -
FINANCE DEPT.
RECEIPT
DATE
BY
D FI LED
INSPECTQR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA .
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Slab GradeReturnAir
_
Ducts
,1 _
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor
Insulation
ents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Fina
Water Piping
Plumbing Final
Plumbing Top Out
_
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
�O
Encapsulation
Gas Piping
_ _
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL
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 011
Utility Notice (Perm)
APPROVALS
,
-
COMMENTS:
u
•
08/30/2004 04:20 FAX 7149212187 ALLIANCE MECHANICAL IM 025
INSTALLATION CERTIFICATE (page 1 of 13) CF -M
Lys —j-7 i0 LAN_ 3 M;
Slte Address (1; -DJ e>VS- 0L0*A PO P4, Permit Number
An installation certificate is required to be posted at the building site or trade available for all appropriate inspections. (The
information provided on this form is required; however, use of this form to provide the information is optional.) After
completion of final inspection, a copy must be provided to the building department (upon request) and the building owns at
occupancy, per Section 10-103(b).
HVAC SYSTEMS:
Heating Equipment
Equip, : IN of Efficiency Duct Duct or Heating Heating
Type (pkg CEC Certified Mir Name Identical VxM etc.)' Location Piping Load Cvtmeiry
IWAn.,4 al,j> AV TU
Cooling Equipment ,
Equip. CEC Certified Compressor N or Efficiency Duct Cooling Cooling
Type (pkg. Unit Mfr Name and Identical (SEER, cta)' l.e®tion Duct Lod Capuiry
1. ? reads greater than or equal to.
1, the undersigned, verify that equipment listed above is: 1) is the actual equipment installed, 2) equivalent to or more
efficient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy
Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for
factored dev' (from the Appliance Efficiency Regulations or Part 6), where applicable.
t� Q —3p og ALLIANCE MECHANICAL HVAC
Signature, to Installing Subcontractor (Co. Name)
OR General Contractor (Co. Name) OR Owner
WATER HEATING SYSTEMS:
- Disuibuuon IrRecv- Nor Rated' Tank Elft• External
Hearer CEC Certified Mfr Type (Std, eulation, Identical Input (kW Volume cieney* Standby* Insulation
Type Name & Model Number Point -of -Use) Control Type systems or Btu/hrl (gallons) _ (EF. REI Loss M R -value'
2 For small gas storage (rated input of less than or equal to 75,000 9tuthr). electric resistance and heal putnp water betters, list Energy Factor.
For large gas storage water beaters (rated input of greater than 75,000 BtAr), list Recovery Efficiency, Standby Loss and Rated Inpuc
For Instantaneous gas water beaters, list Recovery Efficiency and Rated laput.
3. R -I2 external insulation is mandatory for storage water hwters with an energy factor of less than OSE.
Faucets & Shower Heads:
All faucets and showerheads installed arc certified to the Commission, pursuant to Title 24, Part 6, Section 111-
1, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed-, 2) equivalent to
or more efficient than that specified in the certificate of compliance (Form -CF -IR) submitted for compliance with the
Energy Efficiency Standards for residential buildings; and 3) equipment that meets or exceeds the appropriate
requirements for manufactured deviccs (from the Appliance Efficiency Regulations or Part 6), whirr applicable.
Signature, Date Installing Subcontractor (Co, Namc) OR
General Contractor (Co, Name) OR Owner
COPY TO: Building Department
ETERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms August 2001 A-23
r
• WESTERN INSULA'T'ION, L.P.
4211 Latham Street, Riverside, California 92501
Tr1, (951) 686.8760 Fax (951) 6868786
CF6R INSULATION CERTIFICATE
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-
TRACT/PHASE: MT VIEW CC - VISTAS / PHASE 5
LOT* 176
SITE ADDRESS: 50-805 EL DORADO DRIVE, LA QUINTA, CA
--------------------------------------------------
CEILINGS:
BATTS
MANUFACTURER: JOHNS MANVILLE
THICKNESS: 110 R- VALUE: R-30
EXTERIOR WALLS:
BATTS
MANUFACTURER: JOHNS MANVILLE''
THICKNESS: 6 3/4" R- VALUE: R-19
PLUMBING BAYS:
BATTS
MANUFACTURER: JOHNS MANVILLE
THICKNESS: 3 1/2" R- VALUE: R-11
GENERAL CONTRACTOR: TOLL BROTHERS, INC.
BY:
TITLE:
DATE:
•
Li/5Z 3�Jdd
INSULATION CONT CTOR: WESTERN INSULATION, L.P.
LICENS
EAR, BY:
TITLE;
AGER
DATE: AUGUST 30, 2004
NOIiv-lnSNI N�131S3M
98L8989Z56 LZ:ZO b00Z/06/80