0401-335 (RPL)LICENSED CONTRACTOR DECLARATION
' I hereby affirm under penalty of perjury that I am licensed under provisions of
P-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date
LU614611614£1'1 C53 0913OP..i
oZ r- Date !�^ Signature of Contractor 1
J U OWNER -BUILDER DECLARATION
W LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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
LID
N Date Signature of Owner
ON
(3)d Z WORKER'S COMPENSATION DECLARATION
p, Cc I hereby affirm under penalty of perjury one of the following declarations:
F- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
>. 0 � Q performance of the work for which this permit is issued.
00
Q I have and will maintain workers' compensation insurance, as required by
0 0Q Section 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
0)
It Z Carver INSCOrRP -y Policy No. j`;:M00035900
wZ)
r` C3
J (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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
t�•i7 Code, I shall forthwith comply with those, provisions.
,Date: f ! -,/r, Applicant ff//h 1
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
inspectionrpftoses.
�,1-'Signature (Owner/Agent)" iDate
-BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
• e;� .il�bR 100
JOB SITE
ADDRESS IU R111�11?A�t�t..t�'I1
-
APN - -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
A& M CO:1rIT.i`11 Ui TiTON
mmTrmp, Pool.'s &. S`m
78.070 CALIZ CADM
N.O. BOX 1791
3.1, QZti:Q3'.i'A CA 92253
LA. QUDF.1'A CA 92253
e160)360-35135 CBLA 1945)
USE OF PERMIT +{
POOL AND/OR RPA /
POOL .ti4ARAAS/Btk R.RIFI7S SHAT L iii,1*N PLesC9 A.T F'RE-P1.J",.5'E` R
i1 0ii;C.`i'IO1<1, zQ,,,iiPmEA;T Er cLogupi!. WOT RIC1,UDED
P0O1, l NDIOIR SPA 1000.00 i.S
WrIMMIEW COST OF CONSIMUCTION
14l�0is0,C1i7
PLS C';i1EC K FREE 101-000-439-' ) 8 $76,05
CONST Uc:.3IaH MP, 101-000-418-.000 $117.00
EVEC RICALFRE--POOi, ?.1)1.000 i;A0.000 145.00
PLUMBr)<It1 PBX— POOL " 103-f°fi0-X114.000 ��1.aEt
art M e?
FIMAEC�y7•'•q_..y.•�..yy/..t,.,r
�y 'yy +.�^ �v 7 ,r•�1, e�q�
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$G J�.��
LSSI 1•.M. -P1- T.0 MRS
X0,00
f
T0TA.Y,, .P11_% ,1r1' FKES DUE, Y3fC?�1r i
$,20,z 0s
'RECEIPTDA/TE
S
BY ��
DTE FINALE
R
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
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
-C del
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
,.as Piping
Gas Test
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
t7
Y
Final
Utility Notice (Perm)
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MAY -11-2004 07:26 AM
�� 1n C RTIF'ICATE OF FIELD VERIFICATII
/ --
rojecl Title
� Project
,`i%i� t7Qre89
�of
Builder Name
Plan Number
P.01
.>
HER Rater Tplephane Sample Group Number
rtifying Signature Difte Sample House umber
f ,rm: STC. 1- �SSOGi HERS Provider �G.� %�soGfGrCS
Street Andress: 7.Z6�(Ua 4-41WK41 Clry/state21p: Ly 2!i14fft' G
Copies to: Builder. HERS Provider
E RATER COM1,61ANCE ST8LEMENT
The house was; Al 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
com iy with the diagnostic tested compliance requirements as checked on this form.
Distribution system is fully'ducted (i.e., does not use building cavities as plenums or platform returns in lieu
y,of ducts)
,1Z7 where cloth backed, rubber adhesive duct tape Is Installed, mastic and drawbands are used in combination
,_y with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
Y! MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maxlmum 6% Duct Leakage)
Measured
Duct Pressurization fest Results (CFM (§ 25 Pa) values
Test Leakage Flow In CFM
If fan flow is calculated as 400efm/lon x number of tons enter /��p
calculated value here
If fan flow is measured enter measured value here �1
Leakage Percentage (100 x Test Leakage/Fan Flow) e T
Check Box for Pass or Fail (Pass=6% or less) ❑
ass Fail
THERMOSTATIC EXPANSION VALVE TXV or Commission a roved equivalent
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) Is Installed and Access Is provided for Inspection ❑
Yes Is a pass Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
t Q Yes O No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values In
CF -1 R and design on plan,
2. O Yes 0 No TXV is Installed or Fan flow has been verlfled., If no TXV,
verified fan flow matches design from CF -1R.
Measured Fan Flow
Q O
Yes for both 1 and 2 is a Pass Pass Fail