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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. Class Exp. Date '
`I'7°�f`i?� t30/04
Date ��r� °%• Signature of Contractor
OWNER -BUILDER DECLARATION IV
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 & Prof essionals.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 'pen'alty of perjury one of the following. declarations:
(.) I have and will maintain a certificate of consent to self -insure for workers'
compensation, asxprovided'for•'by Section 3700 of the Labor. Code,, for the
performance of the work for which this permit is issued.
( �;) I have andwill 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 ' z f1 C,T ?Ji11T's)1iL7 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or Tess).
() I certify that in the performance of the work for which this permit is issued,
I shall hot employ any person. in any manner so as to become subject to the
workers' compensation'laws of Calilornia, and agree that if, 1•should become
subject to the workers' compensation.provisionsfof Section 3700 of the Labor
Code, I shall forthwith comply with (hose provisions. ✓ ✓� 1
Applican'
Date t
�';? J�" _� %� ..- .�;, ♦ ., , � •
/ _ `►.. ..h r. � �`^""�'�'.\tti/ if
JWarning: Failure to'secure Wopkefs' Compensation coverageIs 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 per onlat
whose request and for whose benefit work is performed under orpurs ant to
any permit issued as a result of this applicaton agrees.to,.& shall, ind�4+� y
& hold harmless the City of La Quinta, its officers, agents and employee%
2. Any permit issued as a result of this application becomes null. and (ojd `f
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 cancell tion. q
I certify that I have read this application and state that the above informat
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 upori.
the above-mentioned property for inspectio�n,p/urp''oses.
I Signature (Owner/Agent) a' ✓ Date r
' PERMIT #
BUILDING PERMIT
DATE VALUATION.tyL 1�SS �vfFn� LOT 128 TRACT
JOB SITE .�F�IdAPxc
ADDRESS
,
APN ')'firx•
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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IWO
7Z_121 PRO) wl�_AWC4100'
73-121 17REDWAR714- .0100
PAt.; A DSS. GAT Cr'i 922-60
PALM DESA r - A 92260
'(760)V14-9699 MIX 3832
USE O�F�PERMIT
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f�OV 1.9 2003�c:
'Icy INTA .-
FINANCE DEPT.
RECEIPT
DATE
BY
D INALED
INSPECTOR '
i
J
4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROV S
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
CZ t j -
I v
Ducts
um Air
Steel
f
Combustion Air
Roof Deck
✓p
Exhaust Fans
O.K. to Wrap
>row
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
_
Grills,
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
BLOCKWAL AP ROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APovAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping •
i
Plumbing Final
Plumbing Top Out
TPool
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
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
Utllity Notice (Perm)
COMMENTS:
08/30/2004 04:20 FAX 7149212187 "ALLIANCE MECHANICAL
INSTALLATION CERTIFICATE (Page I► of 13)
L
a024
CF -6R
Site Address Jbo _ co S 04 4 T7"ALJ%5" Permit Number
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (The
information provided on this form is required; however, use of this form to provide the information is optional.) After
completion of final inspection, a copy trust be provided to the building department (upon request) and the building owner at
occupancy, per Section 10-103(b).
HVAC SYSTEMS: ,
Hearing Egz*ment
Equip. . 0 of Efficiency Duct Duct or Hesting Heaong
Type (pkg: CEC Certified Mfr Name Identical (AFUE, etc.)' Location Piping Load Capacity
un• ii• u•�! .u•5 F'n' h c.
' NA
o 4.n
Cooling Equipment t
Equip. CEC Certified Compressor a of Efficiency Duct - Cooling Cooling
Type (pkg. Unit Mfr None and Identical g
- - - (SEER, etc)' Location > Duct .Lead capacity
)
I
•
A coN - ,
1- > reads greater than or equal to.
I, the undersigned, verify that equipmentdisted above is: 1) is the actual equipment installed, 2) equivalent to or mote
efficient than that specified in the certificate of compliance (Form CF -1R) submitted for compliance with the Energy
Efficiency Standards for residential buildings, and 3) equipment that meets or exceeds the appropriate requirements for
m ufactured d • (from the Appliance Ef cieney Regulations or Part 6), where applicable.
�,,,� ALLIANCE MECHANICAL HVAC
gnature, D e Installing Subcontractor (Co. Name)
OR General Contractor (Co. Name) OR Owner
WATER HEATING SYSTEMS:
Distribution If Recir- q of Rate& Tank Etft- External
Heater CEC Certified Mfr Type (Std, culation, Identical Input (kW Volume tient)^ Standb)t' Insularion
Type Name & Model Number • Point -0f --Use) Control Type Systems or Bmthr) (gallons) (EF. REI Loss 1%) R -value
2 For small gas storage (rated input of less than or equal to 75,000 BuAv), electric restttonce and beat pump water heaters. list Energy Factor,
For large gas storage water beaters (rated input of greater than 75,000 Btirthr), list Recovery Efficiency, Standby Loss and Rated Input.
forinstantaneous gas water bearers, list Recovery Efriciency and Rated Input
3. R-12 external insulation is mandatory for storage water heaters with an energy factor of less than o.53.
Faucets & Shower Heads:
All faucets and 5howerheads installed are certified to the Commission, pursuant to Title 24, Part 6; Section 111.
I, the undersigned, verify that equipment listed above my signature is: 1) the actual equipment installed; 2) equivalent to
or more efficient than that specified in the certificate of compliance (Form CF -I R) submitted for compliance with the
Energy Efficiency Standards for residential buildings; and 3) equipment that meets or exceeds the appropriate
requirements for manufactured devices (from the Appliance Elcieney Regulations or Part 6), where applicable.
Signature, Date 'Installing Subcontractor (Co. Namc) OR
General Contractor (Co- Name) OR Owner
COPY TO: • Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms August 2001 A-23
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