0305-100 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Classxp.,Date !
i� fvF 3 HIC A i /� Gf31�?!
Date -� Signature of Contractor
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'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 & policy no. are:
Carrier STATE FILK) Policy No. i.M5tCd N
(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 subjecj to the
workers' compensation laws of California and agree that if I should become
subject to ttte yGorkers' compensation�provisionslof Section 3700 of the Labor
Code, I shall forthwith comply with �those,provlslons. /
Date:. ^ �; aF) 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 of4is City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)IL r � R ` - Dates
PERMIT #
BUILDING PERMIT
55.10c,
DATE VALUATION S'24 5f t, 40 LOT tidy TRACT 29858-
r
ADDRESS .1'-1io 4IA 1aU:i VVIX
rPN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
P.i Btu:: 810
1.425 z UYI. E211MYY DrR."W:E
LA,QC3INTA CA .0,1,53
P1' (SINJ IM, AZ 8SO34
USE OF PERMIT
k.11.1C�Fe1.C' I rPl'lly� � l I xy 1.' W J :•J�.i..tLi F y
INArli • 3.4. '13Vo 5-�;,Pi S,tY%�{i i. !i�!<Ji'i .. I.iC?.fY.il N&' i1.*WL L;k. IS i;. :
WAL K>014, SP;. OR DRIVEWAr,A,NPROACh
D Q D
TRACT ''ONSTKUC'T104 4,Pa4,P,i BY
JUN U 9
P0iZC1V1lA 1G1 ild.it.lt 3- F
OARAI Oji jC:,AM'C.'RT IM1,N) OF
_
CITY OF LA QUINTA
FINANCE DEPT
ESIM►&AIT,. ID COST OF C -101T 'EWU%' O."kt
M,511.40
K;ijA1;51js;1J4'1`10AiFTE 101.000.419-0011 S1,143.50
PLAN CHIP. ,!K Mk, 101.10100..459.31 a't trig. (5.
MECHAAt,CAI, ME 101-000-421.0010 $1.47.00
MXCTRiChl..ilt?1! $237.92
Pt..r.ttv1B14it3 .FrZ 101-000- t 19 -oclo $2417,:S
STROHO M, OTIGN nE • Y.L31J 101-00 ,41.OW. W.35
CIRADIN fFRE 101-f3N-423-000 $15.00
O04L12,0PER IMPACT FM?,
MIT 1&i PUBLIC 1+W;.FS-.tipXll 270-000-445000
Fi.".Z I)E K43T 101 -WO -439-118 •$1,03i:m
SMUG -'I t l'AL C;tX1M'RUi'"1 01,7 ,'WD I'?' MI OHM=
$5,:3 i &95
54,311 R!5
[RECEIPT
DATE i
BY
DATE FINALED
INSPECTO
C -,j r
INSPECTION RECORD
r OPERATION
DATE
INSPECTOR.
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- -
Ducts
Slab Grade
_ ._
Return Air
Steel
-!P— 3
Combustion Air
Roof Deck
— — -3
Exhaust Fans
OX 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
jVA n)
- �rj
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
- — 2U
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool. Cover
Sewer Connection
_- z
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
JIa
• TAL-LATION CERTIFICATE (Page 3.of 13) CF -6R
Site Address permit Number
DUCTUAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGA REDUC 10N
Pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM)
Fan Flow
If Fan Flow Is Calculated as 400 efmRon x number of tons, or @s 21.7 x Heating Capacity
In Thousands of•Blu/hr, enter calculated value hisre
If fan flow Is measured, enter measured value here
Leakage Fraction - Test Leakagel(Measured or Calculated Fan Flow) a o
Pass if leakage fraction <'0.06 Pass Fall
0 For AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHINO WALL:
b Yes .O N6 . l3 Pressure pan test.or House pressurization test.
0 Yes 0 No 0 Visual Inspection of Duct Connections 0 0
Pass Fall
ER P
^s O No Thetmostatic'Ezpansion Valve is Installed and Access is -provided for. inspection
0.
Yes is a pass / pans Fall
DUCT DESIGN
ACCA Manual D Design calculations have. been
I, C3 Yes 0 No completed, Duct Design is on the plans and duct Installation
matches'plans,,
0 0
2, 0 Yes 0 No TXV is Installed or Fan flow has been verified. If no TXV, Pass Fall
verified fan flow matches design from CF -HL
Measured Fan Flow
Yes for both I and 2 is a Pass
0 1, the undersigned, rcerify that the above diagnostic test results and.the work I pi rformO associated with the test(s) is in conformance
with the requirements for compliance credit. [The builder shall provide the HERS provider. a copy'of the CF -6R signed by the builder
dc.testingaad installation meet the requirements for compliance credit. ]
employees or sub -contractors certifying that diagnos
Tao - Si ra, ate I lling bcontractor (Co. Nae) OR
Pe[formad ,General Contractor (Co. Name)
COPY TO: - Building Department
` HERS Provider (if applicabley
Building Owner at Occupancy
A-25
August 2001
Compllarre F=m
TION CERTIFICATE
C
OL 17'
Jt
(Page 3.of 13) CF -6R
DUCTAAKAGE AND DESIGN DIAGNOSTICS
DUCTLEA"Gg REI)QUION
Pressurization Telt Results (CFM Q 25 PA) test Leakage (CFM)—&
Fan, -Flow
If Fan Flow Is Calculited as 400 cfrrVton x number of tons, or 43 21'.7 x Heating Capacity
In Thousands of -Btu/hr, enter calculated value hore
If tih.flow Is measured, enter measured value- here
Leakage Fraction - Test Leakagel(Measured'or Calculated Fan Flow) a Vr 0
Pass if leakage fraction <0.06 pass Fall
C3 For AEROSOL TYPE SEALANTS' ONLY -The diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured -leakage (CFM)
CHECK AFTER- FINISHING WALL:
0 Yes -.0-N6. ff- Pressure pan tesfor House pressurization -test.
0 Yes 0 No n- Visual Inspection of Duct Connections
Pass: Fail
.g IHERMOSTATIC EXPADMONIALVEITIM
9�Yes Cl No Thermostatic -Expansion Valve is installed and Access is - provided for. ihspection..
0
'Yesis a pass
Pass Fail
Q DUCT DESIGN
ACCA Manual D Design caic.uladons have. been
L 0 Yes 0 No completed, Duct Design is on the plans and duct Installation
matches plans.,
0 0
2. 0 Yes 0 No TXV is Installed or Fan flow has been verified. If no TXV,Pass Fall.
verified fan flow matches design from CF -IR
Measured Fan Flow
Yes for both I and 2 is a Pass
oc, ted ;�,Ith the test(s) is in conformance
test resultj and the work jpeirfo=0 ass ia
0 1, the undersigned, verify that the abQvo diaposdc topy'of the CF -6R signed by the builder
with.tho requirements for compliance credlt- Me builder shall provide the HERS provider. a
employees or sub -contractors ccrtlfylnj; that diagnosdo.testing and Installadon meet the jequiroments for-co'mplianc . c credit..
"Installing bcontructor (Co. Name) OR,
.atUr,",j),t,
Tuts signaturcjDato
General Contractor (Co. 'Name)
Perforrned
COPY TO: Building Department
HERS- Provider (if Applicabley
Building Owner at Occupancy
INST
Site r
TION CERTIFICATE
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUC'I' LEAlsA(s& REVUC"1°ION
Pressurization Test Results (CFM Q 25 PA)
3of1
Test Leakage (CFM)—"
CF -6R
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity
In Thousands of Stu/hr, enter calculated value here
If tan flow Is measured, enter measured value here
Leakage Fraction - Test Leakagc/(Measured or Calculated Fan Flow) n O
Pass if leakage fraction < 0.06 Pass Fail
O For AEROSOL TYPE SEALANTS ONLY -Tbe following diagnostic testing was completed:
Duct Fan Pressurizadon at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
l] Yes 0 No . 0 Pressure pan test or House pressurization test
O Yes O No O Visual Inspection of Duct Connections
0 0
Pass Fall
ff THERMOSTATIC EXPANSION VALVE (TXV)
t 'Yes 0 No Thermostatic Expansion Valve is installed and Access is - provided for. inspection
• >B o
Yes is a pass . Pass Fall
DUCT DESIGN
ACCA Manual D Design calculations have been
1. O Yes O No completed, Duct Design is on the plans and duct installation
matches plans.,
0 0
2. O Yes ❑ No TXV is installed or Fan now has been verified. If no TXV. Pass Fall
verified fan flow matches design from CF -IR.
Measured Fan Flow
Yes for both 1 and 2 is a Pass
0 1, the undersigned, verify that the above diagnostic test results and the work I performed associated with the test(s) is in conformance
with the requirements for compliance credit. (The builder shall provide the HERS provider a copy of the CF -6R signed by the builder
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. j
41
Tad store, Date Installing ubcontractor (Co. Name) OR,
TGeneral Contractor (Co. Name)
en'urrrKd
COPY TO: - Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
A-25
August 2001
Compliance Fomts
INSTALLATION CL.�ERTIFICATE (Page 3 of 13) CF-6R
Si a Add ess Permit Number
,DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCTION
Pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM)
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity
in Thousands of Btu/hr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) _ ❑
Pass if leakage fraction < 0.06 Pass Fail
❑ For AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
❑ Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections ❑ ❑
Pass Fail
Ph THERMOSTATIC EXPANSION VALVE (TXV)
1? Yes ❑ No Thermostatic Expansion Valve is installed and Access is -provided for inspection
Yes is a pass ;W ❑
❑ DUCT DESIGN Pass Fail
Z
ACCA Manual D Design calculations have been
1. ❑ Yes ❑ No completed, Duct Design is on the plans and duct installation
matches plans.
2. ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, ❑ ❑
verified fan flow matches design from CF -IR. Pass Fail
Measured Fan Flow=
Yes for both 1 and 2 is a Pass
❑ I, the undersigned, verify that the above diagnostic test results and the work I performed associated with the test(s) is in confomtance
with the requirements for compliance credit. [The builder shall provide the HERS provider a copy of the CF -6R signed by the builder
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. ]
Tests i , Date Installi Subcontractor (Co. Name) OR
Performed General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms Augtrst2001 A-25
INSTALLATION CERTIFICATE (Page 3 of 13) CF -6R
I Site Address Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DUC,I, LEAKAGE REDUCTION
Pressurization Test Results (CFM @ 25 PA) Test Leakage (CFM) %.
Fan Flow
If Fan Flow is Calculated as 400 cfm/ton x number of tons, or as 21.7 x Heating Capacity
In Thousands of Stu/hr, enter calculated value here
If fan flow Is measured, enter measured value here
Leakage Fraction - Test Leakage/(Measured or Calculated Fan Flow) g,I 0
Pass if Icakage fraction < 0.06 Pass Fail
0 For AEROSOL TYPE SEALANTS -ONLY -Tbe following diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (CFM)
CHECK AFTER FINISHING WALL:
Yes O No . O Pressure pan test or House pressurization test
O Yes O No O Visual Inspection of Duct Connections o 0
Pass Fall
Ef 1HEIRMOSTATIC EXPANSION VALVE
RI Yes D No Thermostatic Expansion Valve is installed and Access is -provided. for. inspection
0
Yes is a pass ass Fall
DUCT DESIGN
ACCA Manual D Design calculations have been
1. D Yes D No completed, Duct Design Is on the plans and duct installation
matches plans.,
0 0
2. O Yes O No TXV is installed or Fan now has been verified. If no TXV, Pass Fall
verified fan flow matches design from CF -{R
Measured Fan Flow -
Yes for both 1 and 2 is a Pass
O 1, the undersigned, verity that the above diagnostic test results and the work I performed associated with the test(s) is in conformance
with the requirements for compliance credit. [The builder shall provide the HERS provider a copy of the CF -6R signed by the builder
employees or sub-contmtctors certifying that diagnostic testing and installation meet the requirements for compliance credit. )
t4 Inq
Ten
Testi TIsim, Date installing ubcontroctor (Co. Name) OR
General Contractor (Co. Name)
Perfomred
COPY TO: - Building Department
HERS Provider (if applicable}
Building Owner at Occupancy
A-25
August 2001
Compliance Forms
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:
50-330 VIA PUENTE ,LOT 46, LA QUINTA,CALIFORNIA
CEILINGS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-21
GENEX(L C, 4TR/CT)6R/RJT HOME' LICENSE #�lL��S 7
011 RAI
��Lgggwp
-
,PA . ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
1
Y: TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/14/2003
Certificate of Occupancy
T ---Mf 4 4 a"
Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 50-330 VIA PUENTE
Use classification: S.F.D.
Occupancy Group: R 3
Owner of Building: RJT HOMES LLC
Building Official
Building Permit No.: 0305-100
Type of Construction: N V Land Use Zone: R L
Address: PO BOX 810
City, ST, ZIP: LA QUINTA CA 92253
By: G. SHOWALTER
Date: 03/29/04
IN A CONSPICUOUS PLACE