0210-237 (SFD)LICENSED CONTRACTOR f DECLARATION
' I hereby affirm under penalty of perjury that 1 -.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££.••��••Classs, Exp. Date
ff 4J9iiV 5 B 5�W A �.� 3r 0/04
,o:Date/�'p` Signature of ContractorZ�
t'
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 (Seca 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Daie Signature of Owner t'
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.
(.f) 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 rc T '3f I;L1P I� Policy No. 1403906.0.
(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. / +
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. a
IMPORTANT 'Application is hereby made to the Director of Building andSafety
for a permit subject to the -conditions and restrictions set forth on:;F is
application..'r'
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 buildinq.
construction, and hereby authorize representatives of this City to enter upon ,
the above-mentioned property for inspection purposes.'
,Signature (Owner/Agent)fl t1 w sf Dater
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BUILDING PERMIT PERMIT#
M
DATE VALUATION LOT TRACT
UWW- M 54
JOB SITE
ADDRESS�.in t° L i
APN
�/ l^f, • �y%
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RA HLDMO T1W
TuT bma t'a14 rs, lK a,
LA Q(j.a'Al.i'AC_ A 922 52,f
Piray.ix AY, 95034
(6q)m.-1.656 C?BLO 4990
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USE OF PERM. IT
TNlm-:FW&iVmy ,
'
SYD • f VI' TQ PLAN 9020C4.—L1f°.kNIT DOPS NOT fbirCLf9DE 31,OG'K
W+.s�I.•L%16C304 SRA OR Of�:t'�+"MAb'',zlPI`"ROA011
PORCI3!RATIO 859.00 sr
0.A.ffAWL'`:��Rf'C?RT �t8?d,t34i �l
:f agyW�'S! IAM E:.`t3g OF �.;•43VIFI"�I'r�".�dO
;X541 ARX1. �)
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W�h/'1�,'I*SFdld'iYaty!"sIT-M .ITEM Yn1- W-419-000�s
F'roI.A1Y CHF -CIC ]PCff.;: � t1�: ••�JL/�/-`�CJei.. S l YS �'1�.lt�A.c�f
MECHANICAL FEE 101.0300.421.000 MOM
RLIXTftlCA. FER 101400-420-000 P2,51.36
P1.,t3MUNG F'A:'C 101 -000 -419 -WO =W-00
5TROHO MOT.IOX 17F - REMID 70 1 -000-2M -000 $26.44
GRAMM PFF, Ilan -000-423- 00
1)L?VL1`L.II>RR1Y1tiPAf:TOG,�a.'
. SUR Cr��€A C��e�i AND PLM.,�lFt'�
/A\ lass Tynly-PA10% luim,
9fi .Y.yA4.o-4'S�.l7f & A`�d:r.'Cp�9 tiAU M.e A'F.Fd.}'Y
n a'!� [, 6
CiTY 0r LA QUINTA
FINANCE DEPT
RECEIPT
DATE rf�'
BY
DATE FINALED— a
INSPECTOFY
J
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set.?Sacks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_ 3
Return Air
Slibel
<3
Combustion Air
Roof Deck
Exhaust Fans
O.K. 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 z Q —5 3
_
Final12ED2./_ _
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
I I
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 y _
Low Voltage Wiring
Fixtures
Main Service _
i Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final j
'Utility Notice (Perm) r
COMMENTS: 4S
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Desem-
ENERGY CABEC
P-0. Box 621 Ph/Fax (760) 564-2044
• Rancho Wage. CA 92270 Cell: (760) 9et;vr a 250- IPJsZ
Email: Wrown62370aol-cam
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF -4R
PA21h , 1,4 1,4 pN. -3D�-�IET�sTE:D
Projec Title //�� ��)
7.70 &Ywae. �L) �/7 �l'ul P Da % un-rl P
Project &ddless wilder Na e
h N PACAggick '�7(od� o?�S-x'377 Vii. ,SG �•� y
Builder Contact Telephone Olan Number
W Z Gg COLJ12#
Raler Telephone Sample Group Number
H
• e ifyi g Signature ' Dae Sample House Number
Firm: P"—e tTF IES - e - e-3 HERS Provider. z•rl•E-F-Q•S.
Street Address: PD • E6 K. 42I City/State/Zip: 49 e-11 0 tiIltA4� Q1 •g227o
,Copies to: Builder, HERS Provider '
HERS RATER COMPLIANCE STATEMENT
The house was: ❑ Tested Q pproved 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 Q 25 Pa) values
Test Leakage Flow in CFM
r 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) _
Check Box for Pass or Fail (Pass=6% or less)' 0 C1
Pass Fail
❑ THERMOSTATIC EXPANSION VALVE (TXV)
Thermostatic Expansion Valve is installed and Access is
C3 Yes 11 No
❑ ❑
provided for inspection.
Yes is a pass Pass - Fail
INSTALLATION CERTIFICATE (Page 3 of 13) CF -6R
1r'1-1rL118ftX_§ 1 -JA
Permit Number
Site.Address
DUCT LEAKAGE AND DESIGN DIAGNOSTICS ry;
DUCT LEAKAGE REDUCTION
--(pressurization Test Results (CFM Q 25 PA) Test Leakage (CFM) J03;
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 Stuft, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction. = Test L,eakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction 5 0.06
Pass Fail
fl For AEROSOL TYPE SEALANTS ONLY - The fonowing 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 ❑ Q
Yes C3 No ❑ Visual- Inspection of Duct Connections pis Fail
❑ THERMOSTATIC EXPANSION VALVE X
Yes ❑ No Thermostatic Expansion Valve is installed and Access is ❑ ❑
provided for inspection Yes is a pass Pass Fail,
❑ DUCT DESIGN
1
Yes ❑ No ACCA Manual D Design calculations have been
_ completed, Duct Design is on the plans and duct installation
matches plans.
2. ❑ y� ❑ No TXV is installed or Fan flow has been verified. If no TXV, '
verified fan flow matches design frorriMeasured Fan.Flow =
❑ ❑
yes for both 1 and 2. is a Pass
Pass Fail
ith the
in
❑ 1,
the undersi ed, verify that the above diagnostic test results and the workiI performed the HERS provider e c py of the (CFs6R.
conformance with the requirements for compliance credit. [I'h�abtuder o pc tpesring and.installation meet the requirements
signed by the builder em oy s or sub -contractors certifying i
for compliance credit.]
Install' Subcontractor (Co. Name) OR
Tests S ,Date General Contractor (Co. Name)
Performed
COPY T0: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
CF -6R
INSTALLATION CERTIFICATE'' (Page 3 of 13) g,
Permit Number
Site.Address
DUCT LEAKAGE AND DESIGN DIAGNOSTICS `
DUCT LEAKAGE REDUCTION
Piessurization Test Results (CFM @ 25 PA) Test Leakage (CFM)_
Fan Flow
N 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 s
If fanflow is measured, enter measured value here
Leakage Fraction Test Leakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction 5 0.06 4; ❑
Pass Fail
fl 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 [3 pressure pan test or House pressurization test ❑' 0
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections • pass Fail
❑- THERMOSTATIC EXPANSION VALVE X
[3 Yes ❑ No Thermostatic Expansion Valve is installed and Access is, . ❑ 0
provided for.inspection yes is a pass Pass Fail
[3 DUCT DESIGN -
1 •
yes ❑ No ACOA Manual D Design calculations have been •
n the plans and duct installation
completed, Duct Design is of
matches plans.
2. [3 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 foi• both I and 2. is a Pass'
Pass Fail
ed d with the
in
perform
O1 the undersigned, verify that the above diagnostic test results and the pro ide the HERS providers a copy of the(CFs6R.
formance with the requirements for compliance credit. [The builder sh P and installation meet the requirements
signed by the builder employ
or sub -contractors certifying that diagnostic testing
for compliance credit J.
ri tall g Subcontractor (Co. Name) OR
Tests lgn a General Contractor (Co. Name)
r Performed
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at .O.ccupancy
INSTALLATION. CERTIFICATE (Page 3 of 13)
CF-4R
Permit Number
Site.Address
DUCT LEAKAGE AND DESIGN DIAGNOSTICS r
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 Btu/hr, enter` calculated value here
+ P If fan flow is measured, enter measured value here
Leakage Fraction.. = Test Leakage/(Measued or Calculated Fan Flow). a ~
' Pass if leakage fraction 5 0.60
' pass Fail
{� For AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
Duct Fan Pressurization at rough-mi measured leakage (CFM)
CHECK AFTER FINISHING WALL:
❑. Yes ❑ No ❑ Pessure pan test or House pressurization test ❑ 0 `
❑ Yes [] No ❑ Visual Inspection of Duct Connections pis Fail
❑- THERMOSTATIC EXPANSION VALVE X
[3 Yes ❑ No Thermostatic Expansion V_ alve is installed and Access is 1
provided for inspection Yes is a pass Pass Fail
❑ DUCT DESIGN
1
C] yes Ll No
ACCA Manual D Design calculations hate been
completed, Duct Design is on the plans and duct installation
matches plans.
2:
13 Yes 13 No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF-IR.
Measured Fan.Flow = ❑
Yes for both 1 and 2. is a Pass
Pass Fail
❑ 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. [Th�bu'dlder shall
testing and. nstallationRS vmeet the prequi requirY of the e
signed by the builder employees or sub-contractors certifying '
for compliance credit-]
41st-al g Subcontractor (Co. Name)'OR
Tests Si ate • Gdnem Contractor (Co. Name)
Performed
COPY T0: Building Department
HERS Provider (if app •hcable)
Building Owner at Occupancy
r«,y l- j '• ' ', _ - ! _moi, - `�-� f � ` ' � .. .y � _• .'" .. ��a
acQ.� a of:.pcc:u ancC ert�fica t Y"W
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id
.p,{ppnnlID��,'' n_,, rte• .• •�+ _ ti �..` .. - - • . �;
Bu ldin &Safety Depa, ent�j .r
OF
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icate=is':issued pursuanUto the requirements of Section. 1& of:the California Building
x Th'is, Certif w
s
th►s: ,structureii' was •in _ compliance a.with t e ;
:Code, ;ce'rtifying- that,:r at -"the time =of -issuance,
a '� and the -various ordinances -:of the.-
"C�ty'regulating building--.�y.
provisions- of the Building Code, -�-
or; use. 4 - � ' .. -�F. • : �- - :� A
con'struc#ion and/�
_ ° 50-455 VIA SIN=PRISA
. - BUILDING ADDRESS: _
,int rf �•s - - � �. . "`` •, � - ..� .r< r - - • �• 4 `� -'�`^ ..' ., R-
j EL'LING r . Building Perrhit No.- 021_
Use classification: SINGLE FAMILY -,DW _
Land 'Use Zone:~ R -L
Type of Construction. -V-N ,
•Occupancy,Group: R-3 - -
f Addressl425 E UNIVERSITY DR. x'
-Owner of Building., .RJT HOMES LLC
City,.ST, ZIP: PHOENIX AZ 85034
_
_•.By: GARY SHOWALTER
•- - -. .. � ' -� t. - - - .' ::Date: 10131 /2003•.. � `. `. `" _ `•
„�•-• f f a • �. s
Bui ding.Official
a
POST IN'A CONSPICUOUS PLACE
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