0402-286 (SFD)LICENSED CONTRACTOR DECLARATION
rn I hereby affirm under penalty of perjury that I am licensed under provisions of
F Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
CN W Professionals Code, and my License is in full force and effect.
O ch License # Lic- Class Exp. Date
LO
LLJ '
CDZ r- Date Signature of Contractor.
O�
r- U � OWNER -BUILDER DECLARATION
W W r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 1, 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
cY) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
M
Q WORKER'S COMPENSATION DECLARATION
CIL
pQ Z I hereby affirm under penalty of perjury one of the following declarations:
r O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �L- compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d 1-- permit is issued. My workers' compensation insurance carrier & policy no. are:
d Z Carrier Policy No. �.
co d!= lit.{9��-Ar
r-O
J (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.
Date: Applicalit' f
A Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned property for inspection purposes.
Signature (Owner/Agent) f' r Date
r
M
BUILDING PERMIT PERMIT# —
DATE VALUATION LOT ,. TRACT
JOB SITE
ADDRESS 14-M i YIR'JN CAA;:
APN
i .3li1 t1F
OWNER
CONTRACTOR/DESIGNER/ENGINEER
R.rr BUMP+ U.:
P'n. -a lrnM4:1+Fn, INC
F10 BOX R] 0
) 4 Z'5. 11k{7VERaVrY r>> 1VF
+. 10Z.)2.57, 16505 CM.# 4990
USE OF PERMIT
31N[:HY FAr LI X 1 WELY.}.NG
Sir13 . t �1'Y ir5, lvl.AN SVISC1. YF:P_WIT PfIF5 NOT ItdL:, -U1)F PC;01.,
SPA, SIXCL Jtli IJ-3, Oft D1RIV F."WAY &PPROACH
TRACT C'.010TRUC"!'RM V VF
POP-CHA'ATIO ND6. 00 :.F
r«,R.AcWCARPORT 10no 0
F-STMA'TFTY COSU Or, CONSi'RM170,1N
I.
P3o:1 tMIT YfIV 6fJMI%A_ t Y
S!OASMUC I V144 Ftp'. 101 .�itiia � }$•.UC.ri� xi,t'13.3iy
i'.Z.AN CHECK i+ E 16 1-CiOtl -433- i 1 I3 197t 15
WCHAN 'A.f. WE 101-WO-42114ft 133' .00
tgZCTRICAL FF..:!{ lf, l-i'i t 420-tt{i0 Z;i3''.41
13111UMP NO IFFIE 101-fA*,+119-(9kt 1261' .
3TRO111 i Mariam PFY. , Rle;.1f) 1(,I 1-tg.Xi i7a1. 5
CIRAC}WO FEE, 1IV1 •ti*1?-42:4-000 a3 I.�_►
rwrva'i,a17>rr4 IMPACT RK
ART IN i'1Fi� I W r.fACM . R?.'iii% 270- 00-443.000 xIt►
90Ti-I'r3' AL, f.'t?llgr.It=AIRD PI,ALT L-IIFJ-,K
(F 3 P,RF 4"IA€i] .M T'S
T0.00
TMAL PT:h'MI >s �+' :S I1t►P: 1fa�Y
I -
�,:tli., 5
RECEIPT
DATE
BY DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Foaiings
Slab Grade
Steel
- - y
- -5
_ 3 - I-
Ducts
Return Air
Combustion Air
s
Roof Deck
Exhaust Fans
O.IC to Wrap
-
F.A.U.
Framing
—
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
01-1
Exterior Lath
Drywall - Int. Lath
Z
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
X - ;3d -y
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wring
- g - I -If
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors :A/
z
Temp. Use of Power
Final
Utility Notice (Perm)
} =-h"',L
ENERGY
S ENERGY
PO_ Box 621
Rancho Mirage, CA 92270
Email: DES NRG &A14 C2M_
Ph/Fax (760) 564-2044
Cell: (7601 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF-4R
PALMILLA PH 7
Project Title
79-560 VIA SIN CULDADO LA QUINTA, CA. 92253
Project Address
CHAD MEYER 760-664-6555
Builder Contact Telephone
RICHARD KROWN 760-250-1852
HERS RateTelephone
OV4- #CCNRK613292 11-18-04
Certifying Signature Date
Firm: DESERT ENERGY SERVICES LLC
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
DATE TESTED 11-9-04
Date
RJT HOMES _
Builder Name
MESQUITE SFICI 3 UNITS
Plan Number
GROUP 5
Sample Group Number
LOT 25 1 OF 3
Sample Lot Number
HERS Provider: CHEERS
City/Slate/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 @ 25 Pa) values
Test Leakage Flow in CFM 92
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
value here 1600
If fan now is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) = 5.75
Check Box for Pass or Fail (Pass =6% or less)
® THERMOSTATIC EXPANSION VALVE (TXV
® Yes ❑ No Thermostatic Expansion Valve is installed and Access is
provided for inspection
® ❑
Pass Fail
MEW
Deseft tr .
E ERGY � --
S�'"� -
PO Box 621
Rancho Mirage, CA 92270
Email: DESURG naCL_CGM
Ph/Fax (760) 564-2044
Cell: (7601 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Pane I of 7) CF-4R
PALMILLA PH 7 DATE TESTED _11-9-04
Project Title Date
79-560 VIA SIN CULDADO LA QUINTA, CA. 92253 RJT HOMES
Project Address Builder Name
CHAD MEYER 760-564-6555 MESQUITE SFICI 3 UNITS
Builder Contact Telephone Plan Number
RICHARD KROWN 760-250-1852 GROUP 5
HERS Rater Telephone Sample Group Number
#CCNRK613292 11-18-04 _LOT _25 2 OF 3
Certifying Signature Date Sample Lot Number
Firm DESERT ENERGY SERVICES LLC HERS Provider: CHEERS
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: M 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 @ 25 Pa) values
Test Leakage Flow in CFM 38
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
%altic here 800
If fan floe is measured enter measured value here
Leakage Percentage (100 x Test Leakage Fan Flow) = 4.75
Check Box for Pass or Fail (Pass =60.. or less) ❑
Pass Fail
® THERMOSTATIC EXPANSION VALVE (TXV)
® Yes ❑ No Thermostatic Expansion Vale is installed and Access is
provided for inspection
De"rt r�
ENERGY . �,1 C A 0 E C
s It��
PO Box 621
Rancho Mirage, CA 92270
Email: Qg, Nj G R_C_L COM
Ph/Fax (760) 564-2044
Coll: (760] 250-1852
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING (Page I of 7) CF-4R
PALMILLA PH 7
Project Title
79-560 VIA SIN CULDADO LA QUINTA,CA. 92253
Project Address
CHAD MEYER 760-564-6555
Builder Contact
RICHARD KROWN
HERS Rater /411,
Telephone
760-250-1852
Telephone
#CCNRK613292 1148-04
Certifying Signature Date
Firm: DESERT ENERGY SERVICES LLC
Street Address: P.O. BOX 621
Copies to: Builder, HERS Provider
DATE TESTED 11-9-04
Date
RJT HOMES
Builder Name
MESQUITE SF1C1 3 UNITS
Plan Number
GROUP 5 _
Sample Group Number
LOT 25 3 OF 3
Sample Lot 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 @ 25 Pa) values
Test Leakage Flow in CFM 118
If fan flow is calculated as 400cfm/ton x number of tons enter calculated
at ue here 2000
If fan flo%% is measured enter measured value here
Leakage Percentage (100 x Test Leakagc Fan Flow) = 5.9
Check Box for Pass or Fail (Pass =610 or less) ® ❑
Pass Fail
® THERMOSTATIC EXPANSION VALVE (TXV)
® Yes ❑ No Thermostatic Expansion Vale is installed and Access is ® ❑
prodded for inspection
ALLATION CERTIFICATE
79-560 Via Sin Cuidado
Site Address
Perrmi
CF-6R
An installation certificate is required to be posted at the building site or made available for all appropriate inspections. (Thc information provided on this form is
required; however, use of this form to provide the information is option I.) Aftcr completion of final inspection, a copy must be provided to the building department
(upon request) and the building owner at occupancy, per section 10-103(b).
HVAC SYSTEMS:
Heating Egrripmenr
Equip. Type
= of
Efficiercy
Duct
Duct or
Heating
Heating
(pkg. heat CEC Certified Mfr, Make R Model
Identical
(AFUE,etc.)'
Location
Piping
Load
Capacity
pump, etc.) Number
Systems
[>_CF-I R value]
(attic, etc.)
R-value
(Btu/hr)
(BTU.,Hr)
FAU CARRIER 58STXI10122
2
80.00,10
ATTIC
R4?
110.000
FAU CARRIER 58STX045108
1
80.0%
ATTIC
R-4.2
45,000
Cooling Equipment
Equip. Type
# of
Effeciency
Duct
Cooling
Cooling
(pkg. heal CEC Certified Compressor Unit
Identical
(SEER, etc)'
Location
Duct
Load
Capacity
pump. etc.) Mfr. Name and Model Number
Systems
[>_CF-I R value]
(attic, etc.)
R-value
(Btu/hr)
(BTUlHr)
AIC COND. CARRIER 38BRC060000
1
12
ATTIC
R-4.2
60,000
.k/C COND. CARRIER 38BRC048000
1
12
ATTIC
R4.2
48,000
_A.'C COND. CARRIER 38BRCO24000
1
12
ATTIC
R4.2
24,000
l >_ reads greater than or equal to.
I, the undersigned, verify that the equipment listed above is: 1) is the actual equipment installed, (2) equivalent to or more cfftcient 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 requircittents for manufactured devices (from the Appliance Efficiency Regulations or Part 6). where applicable.
_ ANIPAM LDI Mechanical
Diana oria r I0i8!2004 HVAC Subcontractor (Co. Name)
OR General Contractor OR Owner
WATER HEATING SYSTEMS:
Water CEC Certified Distribution Type If Recir- Rated Input Tank Efficiency Standby External
Heater Mfr Name & (Sid, Point -of- culation, of Identical (kW or Volume (EF, RE) Loss (%) Insulation R-
Type4 Model Number Use) Control Type Systems Btu(1tr) (gallons) value
FAUCETS g SHOWER HEADS:
All faucets and showcrheads installed arc listed in the Comntisions Directory of Certified Faucets and Showcrlteads.
pursuant to Title-24, Part 6, Subchapter 2, Section 111.
I, the undersigned, verify that the equipment listed in the category above my signature is the actual equipment installed and that the equipment meets or exceeds the
requirements of the Appliance Efficiency Standards. in addition, I have verified that the equipment is equivalent to or more efficient than the equipment specified
on the Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards for residential buildings.
Signature. Date
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
RCR COMPANIES
Plumbing Subcontractor (Co. Name)
OR General Contractor OR Owner
INSTALLATION CERTIFICATE (Pape 3 of 13) CF-6R
C;z5
Site Address Permit rvumoer
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
DU(:1' LEAliAGE REDU(C110 N
Pressurization Test Results (CFM Qa 25 PA) Test Leakage (CFM)-&8
Fan Flow
If Fan Flow is Calculated as 400 efmhon x number of tons, or as 21.7 x 'cleating Capacity
In Thousands'o( BtuRtr, enter calculated value here
If fan slow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow) _ �y ❑
Pus if Icakage fraction <0.06 Pass Fail
Cl For AEROSOL TYPE SEALANTS ONLY -The following diagnostic testing was completed:
Duct Fan Pressurization at rough -in treasured leakage (CFK
CHECK AFTER FINISHING WALL:
❑ Yes ❑ No ❑ Pressure pan test or House presmrizatioa test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections ❑ ❑
Pass Fall
D THEJL'vfOSTATTC EXPANSION VALVE fT
❑ Yes ❑ No Thermostatic Expansion Valve is installed and Access is - provided for inspection
Yes is a pass ❑ ❑
El DUCT DESIGN Pass Fall
ACCA Manual D Design calculations have been
1. ❑ Yes ❑ No completed, Duct Design Is on the plans and duct installation
matches plans.
2. ❑ Yes Cl 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 =
Yes for both I 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 HERS 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. ]
Tesu 5' rc, Date
Performed
COPY To: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms
G Tj i
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name)
August. 2001
R-25
R6TALLATION CERTHICA1E (Page 3 of 13) CF_
Site Address Permit Number
DUCT LEAFAGE AND DESIGN DIAGNOSTICS
DUCT LEA1 AGE REDUC110N
Pressurization Test Results (CFM @ 26 PA) Test Leakage (CFM)—!Zff
Fan Flow
L°Fan Flow is Calculated as 400 cfm'ton x number of tons, or as 21.7 x Heating Capacity
in Thousands of BW/hr, enter calculated value here
If fan flow Is measured, eater measured value here /.20
Leakage Fraction = Test Leakage/(MexsurcJ or Calculated Fan Flow) = O
Pass if leakage faction < 0.06 ass Fail
Cl For AEROSOL TYPE SEALANTS ONLY -The folloi%ing diagnostic testing was completed:
Duct Fan Pressurization at rough -in measured leakage (C M
CHECK AFTER FINISHING WALL:
❑ Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections o 0
Pass Fail
0 THERMOSTATIC EXPANSION VALVE MM
Yes ❑ No Thermostatic Expansion Valve is installed and Access is - provided for inspection y�
Yes is a pass
Pass Fail
❑ DUCT DESIGN
ACCA Manual D Design calculations have been
1. ❑ Yes ❑ 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. ° 13
verified fan flow matches design from CF-1R. Pass Fail
Measured Fan Flow =
Yes far both 1 and 2 is a Pass
❑ b the undersigned, verify that the above diagnostic test results and the work I perforutcd associated with the tests) is in conformance
with the requirements for compliance credit [The builder shall provide the TIERS provider a copy of the CF-6R signed by the bmlder
employees or sub -contractors certifying that diagnostic testing and installation meet the requirements for compliance credit. ]
Tests Datr
Performed
COPY TO. Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
Compliance Forms
L/---r
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name)
August 2001
A-25
Ca S, f%k
DWALLAMON CERTIFICATE E (F age 3 of 13) C'-bR
Ph -'o -5-
Site Address Permit Number
DUCT LEAKAGE AND DESIGN DLAGNOSTICS
DUCT L1CA1CikG REDUCTION
Pressurization Test Results (CFttiI Qc 25 PA) Test Leakage (CFM)3y
Fan flow
If Fan Flow is Calculated as 400 efinhon 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 14
Leakage Fraction = Test LeakagefflMeasured or Calculated Fan Flow) _ ❑
Pass if leakage fraction < 0.06 Vass 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:
O Yes ❑ No ❑ Pressure pan test or House pressurization test
❑ Yes ❑ No ❑ Visual Inspection of Duct Connections ❑ ❑
Pass Fail
❑ TAERMOSTATIC EXPANSION VALVE
Yes ❑ No Thermostatic Expansion Valve is installed and Access is - provided for inspection
Yes is a pass ❑
Pass Fail
❑ DUCr DESIGN
ACCA Manual D Design calculations have been
1. ❑ Yes ❑ 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, ❑ ❑
verified fan flow matches design from CF-Ilt Pass Fail
Measured Fan Flow=
Yes for both 1 and 2 is a Pass
❑ L 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 HERS 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. ]
Tests i- ansre, Date
Performed
COPY TO: Building Department
HERS Provider (if applicable)
Building Owner at Occupancy
- v.:r
Installing Subcontractor (Co. Name) OR
General Contractor (Co. Name)
Compliance Forms August2WI p-25