0401-118 (SATT)s' LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury. that.) 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. l
License # I Lic. Class 4' Exp. Date
fr 90645 B C A Cir ®1r
- ` w F;
Date r;.l-r't ° t Signature of Contractor L
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).
O I am exempt under Section B&P.C.'for this reason
Date Signature of Owner r
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 'S'TATE FUND Policy No. 139,:1906.01
..,(This section need not be completed if the permit valuation is for $100.00 or less).
r () 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 thoseaprovisions. 1
Date: 1.i k' fa,t Applicant >
Warning: Failure to secure Workers' Compensation' coverageisand
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
applicatioh.
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..) 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.
Signature (Owner/AgentDate Z"'' l }
/ 2H
BUILDING PERMIT PERMIT#
18
DATE VALUATION LOT L `1 TRACT
JOB SITE
ADDRESS 5'.0�- 2W /. S Id TIC0
APN
2460-007
772460-007
OWNER
CONTRACTOR / DESIGNER / EN (NEER
_'O �'.•�.? I
1425M iTlv'i3� .3rT
1:A QLMTrA CA, 92253
PROL X AZ 85034
(602)257-1656 C'?U 4990
USE OF PERMIT
MWO
SFA - LOT 1.24, PLAN P23. PERAIT DOES NOT INCLU Dg .P001, SPA,
8W0,K WA!A.%- O:E1 DRIVEWAY AI'PRO.ACK 75% :.RX, DUCTION TO OLr91+f ,
C:111!CK FEE DUE TO fV1U1i.+rXPLE; ISSUANC:Lr OF ;2. MR, F'i.AM TYPE.
7'RAC:'T CONSTRUCTION 3yI9I,OG 3F
Pfr?I?.C:%IipAmo � 569.00 SF
CtAF�AC31?At�.A,F:I't)RT 538,A0 SIS
EMP YA i ED CONT Of, OO.NSTRUC337.0N
CONSTRUCTION FEE 103.000.418-000 3961,0
ALAN CHECK: PT;E 101-000-439-318 $205,62
MECH1+ IC AL b EZ 101 -Q00 -4Z I.000 $1105.00
a` 1, °Riladl L ME 101-.000-4120-000 y W4.95
PLUMMO rFE, 101-000-419-000 3230.98
STI~OM MOTION. F • R&Q.TD 101-000-24,1-000 W.14
GRAD -Nd YEZ 1031.000.423.000 V5.00
DWrELOPER f AVA.CT .FEE $x,001, Oo
MM-L`CiTAL C;ONIMMUCIrION AND PIAW CIM, Olt
$3,74121
W1 M5 Vu Ev. RMs
28 2 'r
^�R CI'TV 01 yr.�� lII2s` Tla 7
EINIM3CE IDEr
RECEIPT
DATE
/_ x
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
Return Air
Steel
•- y
Combustion Air
Roof Deck
O.K. to Wrap
3/ y
Exhaust Fans
F.A.U.
Framing_
y
Compressor
Insulation
$ -` _ y S
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 AP ROYALS
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-
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' P,r L .r•-��.zc `ma/��/y
!A
°
..
INSTALLATION CERTIFICATE (Page 3 of 13)
•;j-
CF -6R
Site Address 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 a'
In Thousands of Btu/hr, enter calculated value here
-
If fah 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:
i
Duct Fan Pressurization at rough=in measured leakage (CFM)
-
CHECK AFTER FINISHING WALL: '
❑ Yes' ❑ No ❑ Pressure pan test or House piessurization test r
•
O Yes ❑ No ❑ Visual Inspection of Duct Connections
o " P
Pass
Fail. '
THERMOSTATIC EXPANSION VALVE (TXV)
t
�! Yes ❑ No Thermostatic Expansion Valve is installed and Access, is - provided for inspection.
` Yes is a pass
❑ DUCT DESIGN Pass
Fail
ACCA Manual D Design calculations have been
1. O Yes O 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,
O
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 conformance
with the requirements for compliance credit. [The builder shall provide the.HEn 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
,.
TestsSi ature, Date' -
- Pe brined Instalim9 Subcontractor (Co. Name) OR
�,.
General Contractor. (Co. Name)
t -
- • —^'`
COPY TO: Building Department }
HERS Provider (if applicable)
Building Owner at Occupancy �+
{
Compliance Forms August 2001
y
,.
.
•• -
Ar25 ,
n
y� INSTALLATION CERTIFICATE (Page 3 of 13)
CF -6R
' Ste Address Permit Number
DUCT LEAKAGE AND DESIGN -DIAGNOSTICS
DUCT LLA-KAGE REDUCTION
Pressurization Test Results (CFM @ 25 PA) Test Leakage (CFM)1(4&
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) _
❑
,fly 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:
)
0 Yes ❑ No D Pressure pan test or House pressurization test
0 Yes ❑ No ❑ Visual Inspection of Duct Connections
1)
❑
Pass
Fail
THERMOSTATIC EXPANSION VALVE (TXV)
Yes ❑ No Thermostatic Expansion Valve is installed and Access is - provided for inspection
Yes is a pass
❑
❑ DUCT DESIGN Pass
Fail
ACCA Manual D Design calculations have been
` 1. D Yes ❑ No
completed, Duct Design is on the plans and duct Installation
matches plans.
r. t
j
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=
c Yes for both,- 1 and 2 is a Pass
!
' O ,I, the undersigned, verify that the above diagnostic test results and the work I performed associated with -the tests) 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 cern Eying that diagnostic testing and installation meet the requirements for compliance credit. j
gature,
• Tests " Date —�
Installin
Performed g Subcontractor (Co. Name) OR
1
General Contractor (Co. Name)
COPY TO: Building Department
i
HERS' Provider (if applicable)
r
Building Owner at Occupancy
p
1
t
Compliance Forms ' August 2001
'
A-25 ,
FiSTAI,LATION CERTIFICATE (Page 3'of 13)
CF -.6R
50 Q05 \1
Site Address 4 Permit Number
DUCT LEAKAGE AND DESIGN DIAGNOSTICS :
DUCT 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 StAr, enter calculated value here
If fan flow Is measured, enter measured value here"
Leakage Fraction = Test Leakagel(Measumd or Calculated Fan Flow) _ N
p
Pass if leakage fraction < 0.06 Pass
Fail
0 For AEROSOL TYPE SEALANTS ONLY -The following diagnostic, testing was completed:
Duct Fan Pressurization at tough -in measured leakage (CFM)
CHECK•AFTER FINISHING WALL:
❑ Yes ❑ No ❑ Pressure pan test or House pressurization test
0 Yes ❑ No O Visual Inspection of Duct Connections
o
Pass
Fail
Of THERMOSTATIC EXPANSION VALVE fTXV)
2fYes o No Uprmostatic Expansion Valve is installed and Access is --provided for inspection
Yes is a pass 11;W
0
❑ DUCT DESIGN Pass
Fail
ACCA Manual D Design -calculations have been
1. o Yes o No
completed, Duct Design is on the plans and duct Installation
matches plans.
l
2. o Yes ❑ No TXV is installed or Fan flow has been verified. If no TXV, o
0
verified fan flow matches design from CF -1R. 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 tests) 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" orsub-contractors certifying that diagnostic testing and installation meet the requirements for compliance credit ]
S tore, Date
Tests----------------------
Performed
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name)
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
ti
cate of Occu anc Y.
ti . _p
Ar
G� OF Buildin &' Safet artrr�ent
,,`De`
•'-, .�` �, ;.. ,, - - .. 1 r ,.fir - - - _ - -� {.,
This Certificate is --issued= pursuant'to -`the requirements of Section, 109 •of the California Building
-
_ _.
Code, cerci ►n' lthat, at - the time ,-of .issuance; u this structure was• ►n .compliance^ w they
fy 9
�th�
provisions of Building"°Code and: the various ordinances aof the City� regulating build►ngH� .•7
,the
construction_ and/or- use..
•
4 5
' BUILDING AD-DRESS:- 50-205 VIA'SIMPATICO
Use `classification ��, s �• A e T r-y " �. Builwding Permit No. •040.1=118
.S.F.D .
- „1:` - - irk. :" _•� -J^ s — ry _• "'' r - '�' ,r '�' i
Occupancy.Group: R-3 Type, of Construction:, V-N ", Land Use Zone: R-L,
�Y-
x`
Owner of Building-RJT HOMES=LLC " ' ` . - Address PO BOX 810
City,. ST; ZIP: LXQUINTA ,CA 92253 s
�t
. •.iw r 1 � ( .-f _ � - ... L ` . r 4 I'..A �: -.. -v L J 2.
by- G-SHOWALTER
4Date: 09/09/04
Y , Building=Official
'A"' a '• -.POST IN A CONSPICUOUS PLACE