BMCH2017-0100LICENSED CONTRACTOR'S 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 Professions Code,
and my License is in full force and effect.
License Class: C20, C36 License No.: 977333 C
Date: 31311 l`7 R Contractor: J
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031:5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
(_) 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon; and who•does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
he or she did not build or improve for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B:&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
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 and polity number are:
Carrier: REPUBLIC UNDERWRITERS INSURANCE COMPANY Policy Number: ATW
+010094
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 provisions.
Date 31 1-7 • Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT .--
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
_ F
Date:_d 3A 1 `I - Signature (Applicant or Agent): A
4
4 4Q"
VOICE (760) 777-7125
78-495 CALLE TAMPICO
FAX (760) 777-7011
ire LA QUINTA, CALIFORNIA 92253
DESIGN & DEVELOPMENT DEPARTMENT
INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 3/27/2017
Application Number: BMCH2O17-0100
Owner:
Property Address: 49171 WASHINGTON ST
RUSSELL BUCKLIN
APN: 646170020
D
P 0 BOX 411
Application Description: BUCKLIN / HVAC CHANGE
OUT14 SEER
MOUNTLAKE TERRACE, WA 92253
Property Zoning:
MAR 31 2011
Application Valuation: $3,000.00
Applicant:
CITY OF LA QUINTA
Contractor:
IE INC
COP.IMUNITYDEVELGPPAENTDEPARTF.1ENT
A#1 SERVICES HEATING & AIR CONDITIONING
31225 LA BAYA
78206 VARNER RD #D-189
WESTLAKE VILLAGE, CA 91362
PALM DESERT; CA 92211
-
(760)565-2691
Llc. No.: 977333
LICENSED CONTRACTOR'S 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 Professions Code,
and my License is in full force and effect.
License Class: C20, C36 License No.: 977333 C
Date: 31311 l`7 R Contractor: J
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031:5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
(_) 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon; and who•does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
he or she did not build or improve for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B:&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
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 and polity number are:
Carrier: REPUBLIC UNDERWRITERS INSURANCE COMPANY Policy Number: ATW
+010094
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 provisions.
Date 31 1-7 • Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT .--
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
_ F
Date:_d 3A 1 `I - Signature (Applicant or Agent): A
4
•R s
`DESCRIPTION ACCOUNT QTY AMOUNT
` S 5
BA61473 FEE 101-0000-20306 0 $1.00
S
t ;Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT - SPLIT -SYSTEM
101-0000-42402
0
$76.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
HVAC CHANGEOUT - SPLIT -SYSTEM PC
101-0000-42600
0
$38.00
Total Paid for CHANGEOUT: $114.00
DESCRIPTION
ACCOUNT
QTY
AMOUNT
PERMIT ISSUANCE
101-0000-42404
0
$96.27
Total Paid for PERMIT ISSUANCE: $96.27.
DESCRIPTION
ACCOUNT
QTY
AMOUNT
TECHNOLOGY. EN HANCEM ENT FEE '"
502-0000-43611
0
$5.00
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CERTIFICATE OF COMPLIANCE
r
Alterations to Space Conditioning Systems (formerly CF -IR -ALT -HVAC)
Project Name:
RUSS BUCKLIN I Date Prepared:
CFIR-ALT-02-E
(Page i of 3)
2017-03-22
A. General Information
CFIR-ALT 02 is applicable to multiple space conditioning systems contained within a single dwelling unit. When multiple dwelling units must be documented, use one
CFI11-ALT-02 document for each dwelling unit.
01
Project Name
RUSS BUCKLIN
02
Date Prepared
2017-03-22
03
Project Location
49171 WASHINGTON
04
Building Type
Single family
05
CA City
LA QUINTA a
06
Dwelling Unit Name
WHOLE HOUSE
Identification or
Location or Area
by this SC
ductedcontaining
07
Zi Code
p
92253 "
08 s
:Dwelling Unit Conditioned
`
1558
Served
System (ft2)
component?
2
Floor Area (ft )
feet of ducts?
duct system?
SC system?
Alteration Type
SYSTEM 1
Number of Space
1558
09
Climate Zone
35
No
Conditioning (SC) Systems in
1
Altered space
this Dwelling Unit:
B. Space Conditioning (SC) System Information
z, .
01
02
03
04 "
0.5 =
My 06
07
08
09
10
SC System
SC System
CFA served
Is the SC.ry
system a" "
rinstallinga
>
refrigerant
Ahitilliftriew SC,
Installing
Installing
Installing
Identification or
Location or Area
by this SC
ductedcontaining
system
more than 40
entirely new
entirely new
Name
Served
System (ft2)
system?
component?
components?
feet of ducts?
duct system?
SC system?
Alteration Type
SYSTEM 1
WHOLE HOUSE
1558
Yes
Yes
Yes
No
No
No
Altered space
conditioning system
C. Extension of Existing Duct System, Greater Than 40 Feet (Section150.2(b)11011b)
This section does not apply to this project.
Registration Number:417-A02006331SA-000-000-0000000-0000
CA Building Energy Efficiency Standards - 2016 Residential Compliance
Registration Date/Time: 2017-03-22 14:39:40
• Report Version: 2016.1.005
Schema Version: rev 10/16
HERS Provider: CHEERS
Report Generated: 2017-03-22 14:39:43
CERTIFICATE OF COMPLIANCE CF1R-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT -HVAC) (Page 2 of 3)
D. Altered Space Conditioning System (Sections 150.2(b)1E and F)
01
02
03
04
05
06
07
08
09
10
-11
12
Heating
Cooling
System
Heating
Altered
Heating
Minimum
Altered
Cooling
Minimum
Required
New or
Identification
System
Heating
Efficiency
Efficiency
Cooling
Cooling
Efficiency
Efficiency
Thermostat
Replaced
New Duct
or Name
Type
Components
Type
Value
System Type
Components
Type
Value
Type
Duct Length
R -Value
Central gas
All new
Central split
All new
This field or
This field or
SYSTEM i
furnace
heating
AFUE
80
AC
cooling
SEER
14
Setback
section is not
section is not
components
I
components
applicable
applicable
Reouired Documentation:
CF2R-MCH-01-E -Space Conditioning Systems R
- Duct insulation requirement for the new portions of supply -air and return -air ducts or plenums ;R6 (CZ 1 10 12 and 13) and R8 (CZ 11 and 14-16)
CF2R and CF3R-MCH-20-H - Duct Leakage Test required when heating or cooling components are Installed InfduI.cted systems, or when more than 40 ft of duct length is replaced
-Leakage rate compliance: <=15% or <= 30% leakage to outside, or seal all accessible. leaks
CF211 and CF3R-MCH-25-H Refrigerant Charge verification required when refrigerant containing components,are Installed or altered (applicable In CZ 2, 8-15).
CFZR and CF3R-MCH-23 Airflow Rate >= 300 CFM per ton required when MCH -25 Is required. + t
Exceptions,`*G '
Duct systems registered with HERS provider as previously sealed are exempt from MCH -20 Duct Leakagel: Ing requirements.
Heating -only systems and Air Handler Furnace changes do not require verification of Air Flow MCH -23, or Refrigerant Charge MCH -25.
-Existing duct systems constructed, Insulated or sealed with asbestos are exempt from MCH -20 Duct Leakage Testing requirements.
E. Entirely New or Com p tete Re p lacement Duct S stem, with or without E" ui menti- Chan 'eotit (Sections 150.2 b iDiia and 150:2 b 1E, F)
p S=cj xh
This section does not apply to this project.
F. Entirely New or Complete Replacement Space Conditioning System (Section 150.2(b)1C)
This section does not apply to this project.
Registration Number: 417-A020063315A-000-000-0000000-0000
CA Building Energy Efficiency Standards - 2016 Residential Compliance
Registration Date/Time: 2017-03-22 14:39:40
Report Version: 2016.1.005
Schema Version: rev 10/16
a
HERS Provider: CHEERS
Report Generated: 2017-03-22 14:39:43
t
CERTIFICATE OF COMPLIANCE CFiR-ALT 02-E
Alterations to Space Conditioning Systems (formerly CF -1R -ALT -HVAC) (Page 3 of 3)
Documentation Author's Declaration Statement
1.1 certify that this Certificate of Compliance documentation is accurate and complete.
Documentation Author Name:
Documentation Author Signature:
Cara Goldberg -
Cara Goldberg
Company:
Signature Date:
A#1 Services Heating & Air Conditioning °
2017-03-22
Address:
CEA/ HERS Certification Identification (If applicable):
78026 Varner Road #D-189
City/State/Zlp:
Phone 1
Palm Dessert CA 92211 ��
(760).342-3610
Responsible Person's Declaration statement 1W
VIb�
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct. ' +
w
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responslbillty for the building design or system design identified on this Certificate of Compliance (responsible designer).
3. That the energy features and performance specifications, materials, components, and ma'nuf,.,,,- d devices for the building design or system design Identified on this Certificate of Compliance conform to the
requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4.: The building design features or system design features Identified on this Certificate of Compliance are consistent with the Information provided on other applicable compliance documents, worksheets,
calculations, plans and specifications submitted to the enforcement agency::for-approval;with this building permit application.
S. I will ensure that a registered copy of this Certificate of Compliance shall be made`avallable with the building permits) Issued for the building, and made available to the enforcement agency for all applicable
Inspections. I understand that a registered copy of this Certificate of C mpilance is egulred fo be included with the documentation the builder provides to the building owner at occupancy.
Responsible Designer Name: i t_a Fy > k v�
Cara Goldberg
Responsible Designer Signature:
C'a'ra Goldberg
Company:
Date Signed:
A#1 Services Heating & Air Conditioning
2017-03-22
Address:
License:
78026 Varner Road #D-189
977333
City/State/Zip:
Phone:
Palm Dessert CA 92211
(760) 342-3610
Digitally signed by CHEERSTM. This digital signature is provided in order
1 to secure the content of this registered document, and In no way, Implies
Registration Provider responsibility for the accuracy of the lnformation.
Registration Number: 417-A020063315A-000-000-0000000-0000 Registration Date/Time: 2017-03-22 14:39:40 HERS Provider: CHEERS
CA Building Energy Efficiency Standards - 2016 Residential Compliance Report Version: 2016.1.005 Report Generated: 2017-03-22 14:39:43
Schema Version: rev 10/16
r