12-1170 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
Property Address:
APN:
Application description:
Property Zoning:
Application valuation:
12-00001170
53600 AVENIDA HERRERA
774-124-006-19 -000000-
SPECIAL INSPECTION
COVE RESIDENTIAL
100
Tiht 4 XP Q" ,
Architect or Engineer:
4 A -
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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 an rofessionals Code, and my License is in full force and effect.
LicensQ Class: B icense No.: 647916
.//�`'(ate� L ontractor:
OWN R•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.).
(_ 1 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.).
(_ ) 1 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:
Lender's Address:
LQPERMIT
Owner:
EASTERN SAVINGS
4195 CHINO HILLS
CHINO HILLS, CA
BANK
PKWY #517
91709
Contractor:
POLAND CONSTRUCTION INC,
4195 CHINO HILLS PARKWAY
CHINO HILLS, CA 91709
(909)591-8040
Lic. No.: 647916
VOICE (760) 777 -
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/04/12
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 policy number are:
Carrier EXEMPT Policy Number EXEMPT
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 t ecome subject to the workers' compensation laws of California,
and agree that, if I should be me N t to the workers' compensation provisions of Section
700 of the Labor Al o it comply with those provisions.
te:w App' nt:
WARNING: FAILURf TO I KERS' 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 Director of Building and Safety 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 nstruction, and reby authorize representatives
of this coun to nter upon the above-mentioned propertyin c ' r as.
D eiv Sig ure (Applicant or Agent)
Application Number . . . . . 12-00001170
Permit SPECIAL INSPECTION
Additional desc . .
Permit Fee 100.00 Plan Check
Fee
.00
Issue Date . . . . Valuation
. . .
. 0
Expiration Date 4/02/13
Qty Unit Charge Per
Extension
BASE FEE
100.00
----------------------------------------------------------------------------
.Special Notes and Comments
SPECIAL INSPECTION TO FINAL OUTSTANDING
EXPIRED PERMITS #06-2722, 06-3119 &
06-640.
Fee summary Charged Paid Credited
=--------------------------------------------------------
Due
Permit Fee Total 100.00 .00
.00
100.00
Plan Check Total .00 .00
.00
.00
Grand Total 100.00 .00
.00
100.00
LQPERMIT
Bin #
City'd LaQutnta •
Btdfdfng & Safety Division ,
Permit 1'i P.O. Box' 1504, 78-495 Calle Tampico
La Qtnnta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
.Project Address: S 3 (� DO A veo t do- / e( -re ra_ Owner's Name: Lc --,q %/2/✓s,0 V,Al S
A
A. P. Number: 7 -7q-
7 -7q- (-a 4 —G O cp
Address: I -75 e IA10
Legal Description:
City, ST, Zip: 614 I1'/ 0 /l/S 1 di-- 9/ %O
Contractor: . 12. Q /0-,q C(
i e-6 6-"f 5 (• fL- N C°
Telephone �U >,`_�l7 &
Address: s� / 9 / N c 14,115 A,-/elj 43
Project Description:
City, ST, Zip= CA r n/v 11-111S,
d
eep
Telephone: 9U' 5-91 �a
State Lic. # : toy % 9 1(0 _
Arch., Engr., Designer:
a,.
City Lie.
�i—o r F< rJ 0 L
�
Address:
v .�
City, ST; Zip:
C7 (0 3I/Cj U (0 0 (o Y l)
Telephone:
Canstrudion Type: Occupancy:
Project type (circle one): New Add' Alter Repair Demo
Sq. Ft: # Stories: # Units:
State Lic. #:
-
Name of Contact Person:.
Telephone # of Contact Person: Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS UNE
# Submittal Req'd Reed TRACIMG PERMIT FEES
Plan Sets Plan Check submitted Item Amount
Structural Caics.
Reviewed, ready for corrections Plan Cheek Deposit
Truss Calcs.
Called Contact Person Pian Check Balance
Title 24 Calcs.
Plans picked up Construction
Flood plain plan
Plans resubmitted Mechanical
Grading plan
2id Review, ready for correctionsRssue Electrical
Subcontactor List
Called Contact Person Plumbing
Grant Deed
Plans picked up S.M.I.
H.O.A. Approval
Plans resubmitted- Grading
IN HOUSE:-
''t Rcvicw, ready for eormcdons/issue Developer Impact Fee
Planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
CERTIFICATE OF COMPLIANCE (FROM CF -6R)
INSTALLATION CERTIFICATE (PAGE 3A(EC) OF 12) CF -6R
Site Address IPermit Number
53600 Avenida Herrera, La Quinta 92253 1 05-5354
An installation certificate is required to be posted at the building site or made available for all appropriate
inspections. (The information provided on this form is required) After completion of final inspection, a copy
must be provided to the building department (upon request) and the building owner at occupancy, per
Section 10-103(a).
HVAC SYSTEMS:
Evaporatively Cooled Condensing units
CEC Certified
Mfr. Name and
Model Number
# of Identical
Systems
EERa
EERb
Duct
Location
(attic,
etc.)
Duct
R -value
Cooling
Load
Btu/hr
Cooling
Capacity
Btu/hr
Freus IOML036048
1
15
17
attic
4,2
❑ Pass O Fail
60000
(2 in 1 condenser)
1
15
17
attic
4.2
48000
EER. = EER at 75 'F wetbulb and 95 ° F dry bulb'
EERb = EER at 65 ° F wetbulb and 82 'F dry bulb
The system comnlies with all elinibility criteria ✓ 2f/ Svstam (3ualifiac ✓ ✓
1.
EER at 95 ° F dry bulb and 75 ° F wet bulb temperature is listed with ARI
0 Pass ❑ Fail
2
EER at 82 0 F dry bulb and 65 0 F wet bulb temperature is submitted to ARI and
published by the manufacturer in accordance with ARI guidelines.
® Pass C] Fail
3.
Presence of TXV is verified, if the ARI certified EERs are based on equipment with
TXVs
M pass ❑ Fail
4
Ducts are tested and sealed in all installations of this equipment.
®Pass ❑ Fail
6
Proper refrigerant charge is verified if compliance credit is taken for this measure
when TXVs are not ir,z;ailed. NA
❑ Pass O Fail
✓ ❑ 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 -1 R) submitted
for compliance with the Energy Efficiency Standards for residential buildings, and 3) equipment that
meets or exceeds the appropriate requirements for manufactured devices (from the Appliance Efficiency
Regulations or Part 6), where applicable.
Installing Subco tract99fj (Co.,N me) OR
General Contr tpr�(06/J�le/hjOR Owner I J. R. Poland Construction Inc.
COPY TO:
Building Department
HERS Rater (if applicable)
Building Owner at Occupancy
14
11-30-2012
1�
CERTIFICATE OF COMPLIANCE (FROM CF -6R).
INSTALLATION CERTIFICATE (PAGE 3B(EC) OF 12) CF -GR
53-600 Avenida Herrera, La Quinta 92253 1 05-5354
An installation certificate is required to be posted at the building site or made available for all appropriate
inspections. (The information provided on this form is required) After completion of final inspection, a copy
must be provided to the building department (upon request) and the building owner at occupancy, per
Section 10-103(a).
HVAC SYSTEMS:
Evaporatively Cooled Condensing Units
The system complies with all acceptance criteria: ✓ D System Qualifies ✓ ✓
1.
Water stays in the water casing.
® Pass ❑ Fail
2
Water pump starts running when the system is turned on.
® Pass ❑ Fail
3
When the water pump is running, verify that all the condenser coils are wet.
M Pass 13Fail
4.
High pressure trip for the compressor is set (per manufacturer's documents) at or
below 300 psig for R22 Refrigerant and at or below the saturation pressure
corresponding to a temperature of 131° F for all other refrigerants
0 Pass ❑ Fail
5
When the water supply to the water casing is turned off and the casing is drained,
the water pump and 'he compressor trip off.
® pass 0 Fail
6.
Condenser coils have a corrosion resistant coating.
® Pass D Fail
7•
Electrolytic protection is installed and the wiring of the protection circuit is intact
® Pass ❑ Fail
$•
Water casing is made up of corrosion resistant material
® Pass ❑ Fail
9.
A blow -down pump is installed for periodic blow -down in order to remove solids
from the wafer casing. Operation of this pump is automatic and is linked to
compressor run time or conductivity of the water in the casing.
® Pass ❑ Fail
10 1
Water casing is sloped downward towards the blow -down pump location
I ® Pass ❑ Fail
❑ 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 CFA R)
submitted for compliance with the Energy Efficiency Standards for residential buildings, and 3)
equipment that meets or exceeds the appropriate requirements for manufactured devices (from the
Appliance Efficiency Regulations or Part 6), where applicable.
Installing Subcontr ctor ( me) OR j. R. Poland Construction, Inc.
General Contract o. ) OR Owner
Signature: Date: 11-30-2012
COPY TO:
Building Department
HERS Rater (if applicable)
Building Owner at Occupancy
15
CERTIFICATE OF FIELD VERIFICATION & DIAGNOSTIC TESTING (PAGE 5(EC) OF 8)
CF -4R
Project Address
Builder Name
53-600 Avenida Herrera, La Quinta 92253
J. R. Poland Construction Inc.
Builder Contact Scott Poland
Plan Number
Telephone 909-241-5533
4
HERS Rater Dave Bricker
SampleGroupNumber
Telephone 760-541-n25
q
Proper refrigerant charge is verified if compliance credit is taken for this measure
when TXVs are not installed. NA
13 Pass ❑Fail
Certifying Signature
Sample House Number
Date 11-30-2012 a
NA
Firm Energy Driven Solutions Inc.
HERS Provider
CaICERTS
Street Address:
City/State/Zip:
P. O. Box 6705
La Quinta, CA 92248
Copies to: BUILDER, HERS PROVIDER AND BUILDING DEPARTMENT
HERS RATER COMPLIANCE STATEMENT
The house was: ✓ M 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 house identified on this
form complies with the diagnostic tested compliance requirements as checked on this form.
✓ ❑ The installer has provided a copy of CF -6R (Installation Certificate).
The system comolies with all eliaibilitv criteria: ✓ ® 'Svstem Qualifies ✓ ✓
1.
EER at 95 ° F dry bulb and 75 ° F wet bulb temperature is listed with ARI
M Pass ❑ Fail
2
EER at 82 ° F dry bulb and 65 F wet bulb temperature is submitted to ARI and
published b the manufacturer in accordance with ARI guidelines.
®Pass ❑Fail
3•
Presence of TXV is verified, if the ARI certified EERs are based on equipment with
TXVs
L3 pass ❑ Fail
4
Ducts are tested and sealed in all installations of this equipment.
® Pass ❑ Fail
5'
Proper refrigerant charge is verified if compliance credit is taken for this measure
when TXVs are not installed. NA
13 Pass ❑Fail
I, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed;
2) equivalent to or more efficient than that specked 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 excee the appropriate requirements for manufactured devices (from the.
Appliance Efficien Reg ti r Part 6), where applicable.
1( A r,�� J. R. Poland Construction Inc.
SignaturkToInstalling Subcontractor(Co. ami
General Contractor (Co. Name) OR
Owner
COPY TO:
Building Department
HERS Rater (if applicable)
Building Owner at Occupancy
17