0309-233 (SFD)LICENSED CONTRACTOR DECLARATION
I�heereby affirm under penalty of perjury that I am licensed under provisions of
GI;apter 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. Class Exp. Date
t13 �J 33 d7JC ani^^1 + 1:3011}A
Date ' —^ a. Signature of Contractor K
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.
(tV 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 Policy No.
19TAT It, PIT. IN r) W3906-02
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
gate" Applicant—
le, J r
' 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
1 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 inspection purposes.
Sjgnature (Owner/Agent) f / / Date
BUILDING PERMIT PERMITk
DATE VALUATION LOT 030* 213 TRACT
-�, '• -2,, . -3 S24;4,53.A,40 40 29Tt.��-1
JOB SITE —
APN
ADDRESS W-335 WA P YMMM�
OWNER
CONTRACTOR / DESIGNER / EN &NEER
PO BOX, 8) S)
14125 F- 7Dt3`?'kms.". 3. Y MINE
(W2)257-1,656 C, U4 49190
USE OF PERMIT
=2'":t• Let 'f'A0, �E.A�7: 11iC7. PLRM3' �.is7 1'?dCl� lNC1 V1) B' CK
MALL, 3; P004 GPA OR DWAVAY .A,1:IPROAC1£
TRACT CONSTRUCTDO."N 4,024.00 �VF
1�+JR.C:11/lar l°fC3 10.00 Sr
OWRA0YJCAR P0RT ;"F
Z,1V, 1?d Kf. C,,10Rc r OF CO3,K'r71V.1TCM0..N
2,1K1.51.1,40
CONSTRUCTION FF31 till -000-E' 8-000 Sl,'s43.30
nstW CH.TCK FEE ?01-000.439-318 $'.15
+IEC AMAOA,: VEZ -000..121 11O00 $137,fle
.I 1+CTRPC:��:. HSP 101
PLiu Kul NCf FRE 10).-( C-419.000 1.26.13
SMONO'NIMUON FE R = R1TS1I) 101-000-2414M, §124.3.5
i.1k4U!Wt.1 101.000.423.000
1?1rrVZL4:)K`M i•i PAC"T FEMT
mu 111 K.11,4UC PLAi1 N . R.f7llr Z70.OUG- 443.00;3 X08118
�{�l-B-'I��. �' e �' �4 ;%ZY: TTICNV ANDyyyy{'Il aiT( �t 1�1
.�0 :141 6,OBJ'
r9i �•
(
T 0 6 2GH15 r o ., 'EBW
RECEIPT
DATE
BY
DATE FINALLEED)
INSPECTOR_
INSPECTION RECORD
1
! 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 f
O.K. to Wrap
,3 - s -,f
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 g—
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
(f:,/.e> p
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
Gas Piping
Gas Test
Appliances
Final
Final - _ ti
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring a
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: �'ed«�-�-=' 2 - 4 IV
INSULATION CERTIFICATE
This is to certify that insulation has been installed in confon-nance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building at
50-335 VIA PUENTE LOT 40, LA QUINTA CA
CEILINGS:
TYPE:BATTS MAUNFACTURER; Certainteed THICKNESS: R-38
WALLS:
TYPE:WALLS MANUFACTURER: Certainteed THICKNESS: R-21
GENERAL CONTRACTOR: RJT HOMES LICENSE#
By., TITLE:
PARAGON SCHMID BUILDING PRODUCTS A MASCO Company LICENSE # 221517
,vZ
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 inth e buildinglo ed at
cat
CEILINGS,
TYPE: SLOW MAUNFACTURER, Certainteed THICKNESS: R-38
WALLS:
TYPE: BATTS MA FACTURER:
GENERAL
BY:
TITLE:
THICKNESS: R-13
LICENSE #
PAF(AGON SCHMID BUILDING PRODUCTS SCO Company LC
SCO Company LICENSE # 221517
TITLE: ACCOUNT REPR NTIVE DATE:
ITLE: ACCOUNT REPRESENTIVE
DATE:
ay
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 inth e buildinglo ed at
cat
CEILINGS,
TYPE: SLOW MAUNFACTURER, Certainteed THICKNESS: R-38
WALLS:
TYPE: BATTS MA FACTURER:
GENERAL
BY:
TITLE:
THICKNESS: R-13
LICENSE #
PAF(AGON SCHMID BUILDING PRODUCTS SCO Company LC
SCO Company LICENSE # 221517
TITLE: ACCOUNT REPR NTIVE DATE:
INSLA L' TION CERT�'ICA,TE '('Page 3 .of
CF -6R
Site Xddrass Permlt Number.
DUCT -LEAKAGE AND DESIGN DIAGNOSTICS
llt1(,"1' LEAKAGL� itk}DUC,"i`iUEV -
Presiurization Teit Results (CFM Q 25 PA) Test Leakage (CFM) .i ,
Fan•Flow
I -Han Flow is Calculated as 400 cfrn/ton x number of tons, or las 11'.7 x Heating Capacity
In Thousands of•Btumr, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction - Test f,eekagd(Measured'or Calculated Fan Flow) - .Al�r' O
Pau if Icak4go 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 FINISHING WALL:
b Yes D No . d* Pressure pan test or House pressurization -test.
O Yes O No S Visual Inspection of Duct Connections 0 0
Pass Fall
ER STATIC EXPANSION'VA43EVi '
Ycs O No Ttiermostatic•Expansion Valve is Installed and Access Is - provided for. inspection
Ycs'is a passP '. F
• Pass Frill
O DUCT DESTGN
ACCA Manual D Design calculkdons.have.been
1•. l3 Yes. O No completed, Duct Design -Is on the plarls and duct Installation
matches plans.,
' 0 0
2. O Yes O No [ XV is installed or Fan ttow'has been verified. If no TXV, Pass . Fall
verified fan flow matches design from CF -M
Measured Fan Flow -
Yes for both I .and 2 is- a Pass
0 1, the undersigned, yerlfy that'the above diagnosdo test resulti >ytd the work I perfor d associated with are test(s) is in con forrnancc
with the requirements for compliance credit. [The builder shall provide the HERS provider, a ropy of the CF -6R signed by the builder
diagnosde.testing and Installation meet the requircments for comptiance credit. ).
employee orsub-contractors certifying that
C J. f , / i..f l •. /�.a
Tata *' Signaturee ,Cam installing Subcontractor (Co. Natne) OR
Performed General Contractor (Co.
COPYTOi - Building Department-
', HERS Provider or applicable)'
Building Owner at Occupancy
o A-•2 5
_. AAA4
EM
INSTALS TION CERTIFICATE 3.of 13).. CF -6R
VIA
%M9 MUW1 goo
DUCT -LEAKAGE AND DESIGN DIAGNOSTICS
PA) Test Leakage (CFM)
Presi4rlzatlon Teit Results (CFM Q 25
Fad•Flow
If Fan Flow Is Cal6uldled as 400 cfrW.ton x number of tons, or 4s. 21'.7 x Hedfilig Capacity
In Thousands of-ft/hr, enter calculated value here
If fan flow Is measured, enter measured value- here
Leakage Fraction -Test Leakagel(I'dea'sured-or Calculated Fan Flow) -,
Pass'If leakage fraction <0.06
Pass Fall
0 For AERbSCFL TYPE SEALMSITS' ONLY-T4following diagnbstic testing was completed:
Duct Fan Pre.siprization at rough -in measured leakage (CFM)
CHECK AFTER FrNismo WALL:
0 Yes V Nd ff- Pressure pan test. -or Hods; presturization- test.
0 Yes 13 No -0: Visual Inspection of Duct Connections
0 13
Pass Fall
W 1HERMOUAVC EXPADISION'VA.LVE (TM
. Yes 0 No Thermostatic 'Expansion Valve Is Installed And Access Is - proyidcd. for. inspection
'Ycs*is a pass
Pass Fail
0 DUCT DESIGN
ACCA Manual D Design calculations have. been
L 13 Yes 0 No completed, mpleted, Duct Design -Is, on the plans and duct Installation
matches plans.,
2. 0 Yes 0 No TXV is Installed or Fan flow has been verified. If no TXV,
0 '0
Pass Fail
verified fan flow matches design from CF -IR.
Measured Fan Flow
Yes for both land 2 is- a Pass
Q 1, the undersigned, verify thafthe . above diagnostic test resulti apd the work 1piafbrmed associated with tire tests) is in conformance
with the mqufrcrmt3 for cornpllindo'credit. Me builder shall provide the HERS
S provider *a topy*of the CF -6R signed by the builder
employees or subcontmetors certifying that diagnostic.testing and Installation mat the requirements for compliance cr . edit. 1.
Tats —cewt—urciDate 7nstalllng Subcontractor (Co. Naha) OR
Performed General Contructor(Co.'Nimc)
COPY70i BuildinSDepartment.
HERS Provider (if applicableY
Building OOMcr at Occupancy
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7)
PALMILLA
Project Title
50 TH & JEFFERSON
PH 5-B
07-12-04
Date
R J T BUILDERS
CF -4R
Project Address DARRELL MORGAN 760-275-8230 Builder Name
MEAQUITE SFIC1. 3 UNITS
Builder Contact Telephone Plan Number
RICHARD KROWN 760-250-1852 GROUP 3 3 OF 3
Hr;Rs Rater /,/�Telephone
(� #CCNRK613292 07-12-04 LOT # 40
Certifying Signature Date
Firm:DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
Sample House Number
HERS Provider: CHEERS
City/State/Zip:
RANCHO MIRAGE CA. 92270
HERS RATER COMPLIANCE STATEMENT
The house was: ® 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, rubber adhesive duct tae is installed, mastic and drawbands are used in combination with cloth
backed, rubber adhesive duct tape to seal leaks at duct connections-
® MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM CL25 Pa) values
Test Leakage Flow in CFM 31
If fan flow is calculated as 400cfin/ton x number of tons enter calculated
value here 800
If fan flow is measured enter measured value here
Leakage Percentage (I 00 x Test Leakage/Fan Flow) = 3.875
Check Box for Pass or Fail (Pass=6% or less) ® ❑
Pass Fail
® THERMOSTATIC EXPANSION VALVE (TXV)
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ® ❑
Yes is a pass Pass Fail
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PALMILLA PH 5-13 07-12-04
Project Title
50 TH & JEFFERSON
Project Address DARRELL MORGAN
Builder Contact
HERS Rater
RICHARD KROWN
Date
R J T BUILDERS
760-275-8230 Builder Name
MEAQUI.TE SF1C1. 3 UNITS
Telephone Plan Number
760-250-1852 GROUP 3 2 OF 3
Telephone
#CCNRK613292 07-12-04 LOT #
Certifying Signature
Firm:DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
Date
40
Sample House Number
HERS Provider: CHEERS
City/State/Zip: RANCHO MIRAGE CA. 92270
HERS RATER COMPLIANCE STATEMENT
The house was: ® 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, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth
backed, rubber adhesive duct tape to seal leaks at duct connections-
® MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM Lk25 Pa) values
Test Leakage Flow in CFM 74
If fan flow is calculated as 400cfrn/ton x number of tons enter calculated
value here 1600
If fan flow is measured enter measured value here
Leakage Percentage (I 00 x Test Leakage/Fan Flow) = 4.625
Check Box for Pass or Fail (Pass=6% or less) ® ❑
Pass Fail
® THERMOSTATI.0 EXPANSION VALVE
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ® ❑
Yes is a pass Pass Fail
I
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PALMILLA
Project Title
50 TH & JEFFERSON
Project Address DARRELL MORGAN
Builder Contact
HERS Rater ,,
RICHARD KROWN
PH 5-B
07-12-04
Date
R J T BUILDERS
760-275-8230 Builder Name
MEAQUITE SFIC1 3 UNITS
Telephone Plan Number
760-250-1852 GROUP 3 1 OF 3
Telephone
#CCNRK613292 07-12-04 LOT # 40
Sample House Number
HERS Provider: CHEERS
Certifying Signature Date
Firm:DESERT ENERGY SERVICES
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
City/State/Zip: RANCHO MIRAGE CA. 92270
HERS RATER COMPLIANCE STATEMENT
The house was: ® 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, rubber adhesive duct tape is installed, mastic and drawbands are used in combination with cloth
backed, rubber adhesive duct tape to seal leaks at duct connections-
® MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM CL25 Pa) values
Test Leakage Flow in CFM 58
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 2000
If fan flow is measured enter measured value here
Leakage Percentage (I 00 x Test Leakage/Fan Flow) = 2.9
Check Box for Pass or Fail (Pass=6% or less) ® []
Pass Fail
® THERMOSTATIC EXPANSION VALVE
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection ® ❑
Yes is a pass Pass Fail