0203-375 (SFD)LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
QM License # Lic. Class Exp. Date
ti LUti
rZ r— (- Date , '` '-' t Signature of Contractor
cD _
J U p OWNER -BUILDER. DECLARATION
HLu I hereby affirm underpenalty of perjury that I am exempt from the Contractor's
co License Law for the following reason:
Z_ ( ) 1, 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'') O I am exempt under Section , B&P.C. for this reason
LO
N Date. Signature of Owner
ON
a Z WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
H 0 O 1 have and will maintain a certificate of consent to self -insure for workers'
W compensation, as provided for by Section 3700 of the Labor Code,; for the
J Q performance of the'work for which this permit is issued.
Q 0 - q.) I have" and Will maintain workers' compensation insurance, as required by
bU Q Section 3700 of the Labor Code, for the performance of the work for which this
i LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
ao Carver Cat?1;L);1J 1:`t�tiS,Ci if?I Policy No. t41>1YC°>f�tFf2 i1,f
0
J (This. section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performance of the work'forwhich 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: Applicant_lb Warning:, 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 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) Date r
r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 19 TRACT 24191 -5
JOB SITE
APN
ADDRESS 79.492 11PRW4.NG-9 WAY
6044.'r2.016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
(ITNL'URY C",I�LUtdrffi I.. C0A1V"L1Nrrl1W8
(II)'.C•IDk
1535 so, VDII Z'.1RTWIT, 61TILe. 0200
il4 LII)
SAN I3EWA4+ L)114 7 C.A. 92408
8,f N R1`7.Z'AIAR. ,rY11.10 CA 9'24CA',
USE OF PERMIT
3F,T) - is 0T i:9 PI.A,A14 2C. PERMIT DOES Ni' T INCLKIT.?2 Bt Q �X 'W:AR..' A
P0011, SFA OR 1"?dZIVWAY APPROACH.
REDUCTION Y+rlf'a MIJUF'IPIX I3SUANC E• OF SAME PIJVR 'f•YPF
TRACT CONS_I RUCTRY0 0(10-11}0 2F
PORC HIPATIO 3 .f1J aF
t:1.AFtAWCARFC).RT 412,:pt7 COF
ESi'a.'JI.Da�A'I E D C09T QF C'-ORSfRV3C.1171011
8%?38-`i-N)
P..FRMrrTo'WJKMARY
CONSTRUCTION VU? 101=000_x•18.000 $544.;,0
PLAN CHECK FEE 101,00 -439-3 118 l 1?A..%
MECHANICAL MEE 101.000-421.000 VN150
LR.ECTR.ICAL F XF 101-000.420-004 $10e,.7A
PLUMB- NO Fu 101-000-419-000 'S11?91 0
STR(3140 MOTION FFE - Ft'I0D 101-000-241.000 $3. 99
(IRADINO WR9 101.000.42;3-•U0i? X10.00
lai Iri i3l'E:I< 13 I'>.AC'!' 1?I<,E $1,9T7.r30
ST. R1Tal'KL C10),1 .TTCdr0X MID (!LAN C;k=K
LESS :1''iZE-PAR37REZ
lt3,fJ0
_t, :i'1rT�i"1<s 1jT%iu W
MAY 12002
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CITY0FLAQj111TA
FINANCEDEPT.
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
--
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- - -
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-F
�—
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
—ty
Return Air
'Steel
Combustion Air
Roof Deck
Z
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
-- —p
Compressor
Insulation
_ a 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party -Wall Insulation
Condensate. Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
A9 - 2,-6z
Final
Final
BLOCl`rZWALL APOROVALS
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
- Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sever Connection
Encapsulation
Gas Piping
Gas Test
. O -0" -O
Appliances
Final
COMMENTS:
Final
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) j • .aL S7
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This: Certificate issued pursuant to the .requirements of Section 909 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction of use. For the following:_
BUILDING ADDRESS: 79-392 HEMINGS WAY
Use Classification; 'SINGLE, FA. MILY .DWELLING Bldg.. Permit No;.,0203-375
Occupancy Group: 13=3 Type of Construction.; VN Land, Use Zone: RL
Owner of Building: CENTURY CROWELL COMM.
Building Official
Address: 1535 SO. "D" STREET #20.0
City: SAN BERNARDINO; CA 92408
By; STEVE TRAXEL
Date: 1242=2002
POST IN A CONSPICUOUS PLACE
Z004
10/09/2013 23:11 FAX
INSULATIQN CERTIFICATE H
This Is to certify that insulation has been installed in conformance with the current energy
regulation, California Administradve;Code, Tk1e 24, State of California, In the building located at: h
s
79,792MOmings Way, Lot 19, Montlaello-Claissias, La Qulnta, COINOMip `s
s
L
TYPE: MANUFACTURER; Certeinteed Thickness: R-36
W
TYPE: BAITS MANUFACTURER: Certainteed Thickneee: R-13
GENERAL CON RACTOR. CENTURY CROWELL.COMMUNMES LICENSE # O��
BY: TITLE,:
i
i
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE #,832072.
By TITLE: ADMINISTRATIVE ASSISTANT DATE: 1216/2002 '
e
S
I
CERTIFICATE OF-FIELDVERIFICATION AND DIAGNOSTIC TESTING (Page 1 of 7) CF -4R
itle
ress
TFS�� r1Z4-/o z.
bates
C! �t�Tt_1'2Y n ►�E�
Builder ame
Ian Number
tt 120 Li P �
Sample Group Number
Lo # 1o) 12-29,2
cc Sample House Number
Fitm:DE6E.12T L E(Z `( EQ�/I E� HERS Provider: 6. ..�:• E. R.S.
Street Address: P.OY, (Z 1 City State/Zip: ,�� �I r 4t= G°A•�'LL7o
Copies to: Builder, HERS Provider j
HERS RATER COMPLIANCE STATEMENT
The house was: 1:1 Tested Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification. I certify that the houses identified on this form comply
with the diagnostic tested compliance requirements as checked on this form.
❑ The installer has provided a copy of CF -6R. (installation Certificate.
❑ Distribution: system is fully ducted (i.e., does not use building cavities as plenums or platform returns in lieu of ducts)
❑ Where cloth backed, rubberadhesive duct tape is installed', mastic and drawbands are used in combination with cloth
backed, rubber adhesive duct tape to seal leaks at duct connections.
❑ MINIMU.M REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct. Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM'(@'25 Pa) values
Test Leakage Flow in CFM
If'fan flow is calculated as 400cfm/ton x number of tons enter =calculated
value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) = -
Check Box for Pass or Fail ( .Pas$=6% or less) ❑ ❑
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
❑ Yes ❑' No Thermostatic Expansion Valve: is installed and Access is 1:1 [3provided for inspection
Yes is a pass Pass Fail
13 MIN:I'MUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1,. ❑ Yes ❑ No ACCA Manual D Design requirements have been, met(rater has
verified that actual installation matches values in CF- I R and
design on plan.
'-• Yes ❑ No TXV is installed or Fan flow has been verified. lf.no TXV,
verified fan flow matches design from CF -1R.
Measured Fan Flow= ❑
Yes for both. I and 2 is a. Pass Pass Fail
Compliance Forms August 2001 A-16