0307-340 (SFD)LICENSED CONTRACTOR DECLARATION
IIS `t hareby 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. Class '� Exp Date;,,.
• t (1 yy YYpy����•• /' + � F Jar/��� �/� /�/�,.
,C7 ��'S 13 ��t V"'
Signature of Contractor•% -�
' OWNER -BUILDER DECLARATION
Lhereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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",pfoject (Sec: 7044', Business & Professionals
Code).
() I am exempt under Section'-, B&P.0 for this reason
Date `` Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaltyrof perjury one pf the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for l y 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
S7ection 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..
(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'permitis issued,
I shall not employ any person in -any manner so as to become subject to the
workers' compensation laws'O`f California, 4nd°agree".that..if,l should become
subject to the workers' compensation provislonS of�Section-37•_ 00 of the Labor
Code, I shall forthwith comply with th* provision's. ✓`
Date: 2, x Applicant,,JJ.!�'
---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. I
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 a+ d yvoid if r
work is not commenced within 180 -days from date of issuancq 0'such
permit, or cessation of,:work'for 180 days will subject permit to cancellatio Selo
I certify that I have'read this application and state that the above int
correct. I agree to comply with all City; and State lawsjelating to i
construction, and hereby��a'uthonze �eo� sentatives-of this City to
the above :mentioned -of oDertv:for.InsoecLon:ourooses.
I Signature
upon;ir
Date/' -�
BUILDING PERMIT: PERM T.#..
DATE VALUATION LOT µ k. m TRACT
JOB SITE
APN
ADDRESS
80,9.15A ' . ITK A X77f,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
M
3F'?.t�Li✓?Y21!''';��.ppIl...i+!L�,C!tt�++�.g1'A9��.y4a-W �� d ip{ i��9.�}.�y^�
J%A_VTF ,
7 00NWgy:} mw.wC I 'h �7:"a:y5�'6�:}�.
�. 105
J�V,.'�`Y �
1Y\D
.,a
'1424
'f
aa7'01ngA` CA 9402
USE OF PERMIT
i,'[� % i.xk � ,:11?l.:h�l 4,fi �?>Ax:MIl l' ,C?0�5 2dta'f.l`I.dt.".WJt7?? Z;LC'►C:'x oi�frl.f:�T.�, '
TRACT C;t7N;YITIUC1ION 1,11740,0 S
617.0:. '
M0 SIF
�s�/.6.fS.l E,D i.c*r o �N U•�`tl�wdL:G4L1�6F•3 h��•pJ��
AI�f�N(?e]�.��
GOId€ M()CT1014 FEE 101-000- 48-00100 x¢1,5
PI:Ml tat XC:.K FRE, Y U9 (3Ci'Q-r93S'-'s k $;i6z1.4 ;
'�i��C?�l,�l+dic:�. X17 1 Cf t �Utitl�y�� 2 •(itJfa �R6,0�
PLUMBINQ ITTE 101 -000-419-000
S'i'Ai.OM MGT ON ! ISM'' ,• 12., It . 101 --D00-141 -000�l341.`➢b
G -PA 1INGrES 313.0
,C3MEL.CJPFR9A1ukCI ' PES
$4j01-1.34.
i{�I
p ' '� •t'b�''� 1�'�'�'I' a�1v' 3�'� �1?: y�c�'�;t;• -
- �S,43i.:1 R 3�!
V 24 2003
1:,OF LA C UINTA
�9Amr i; nr-
.
-RECEIPT'” �-
DATE'
BY' F
INSPE TO
�{ALED
INSPECTION RECORD
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
OX to Wrap
Z
F.A.U.
Framing
G
Compressor
Insulation
z
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
Equipment Location
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
J/
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Z
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:
CERTIFICATE OF FIELD VERIFICATION AND DIAG
IOSTIC TESTING
Project Titl // j uate 1
J - �S 75lrfr
Proiect Address Builder Name
Builder Cont ct I elephone
/ 5 3
HER Rater Tel phone
Plan Number
CF -4R
Sample Group Number
rtifying Signature Oat6 Sample House Number
Firm: SC. HERS Provider: J76 -•f A,--a6/iZ5S
Street Address: %Z,:(0 X"d-Fa 4 Clr'G6, _- City/State/Zip: L9 0(41ni6 C69 9�2; 3
Copies to: Builder, HERS Provider
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
co?Iy with the diagnostic tested compliance requirements as checked on this form.
Q� 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 @ 25 Pa) values
Test Leakage Flow in CFM 105
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) _. ✓' J
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
,RTI-Y'es ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
Yes is a pass .
❑ MINIMUM 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 -1 R and design on plan.
2. ❑ Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -1 R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
ras
D Fail
N)W
❑ ❑
Pass Fail
it
!•9
`4
,- Certificate of Occupancy
Loo�oew7rn �.�
G� OF 1Building & 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: 80-956 VIA PUERTA AZUL
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0307-340
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: PUERTA AZUEL PARTNERS Address: 17700 SW UPPER BOONES FERRY
City, ST, ZIP: PORTLAND OR 97224
By: GARY HARTMAN
Date: OCT 6, 2004
Building Official 7
POST IN A CONSPICUOUS PLACE