BRES2019-007678-495 CALLE TAMPICO D "i - Q"
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype: BUILDING RESIDENTIAL/REMODEL
Application Number:
BRES2019-0076
Property Address:
51830 AVENIDA MORALES
APN:
773152004
Application Description.
CHANGE OUT (8)WINDOWS
Property Zoning:
Application Valuation:
$1,000.00
Applicant:
GIRARDIN, GERI
51830 AVENIDA MORALES
LA QUINTA, CA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 70001 of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.:
Date
Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
( I, as owner of the property, or my employees with wages as their sole
kensation, will do the work, and the structure is not intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
he or she did not build or improve for the purpose of sale.).
I, as owner of the property, am exclusively contracting with licensed contractors
nstruct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the contractors' State License Law.).
( I am exempt under Sec. . B.&P.C. for this reason ._
Date: _ '](fICY 11v1 Owner:
CONSTRUCTION LENDM AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Owner:
GIRARDIN, GERI &ROBE
:J��
51830 AVENIDA MORAL;
LA QUINTA, CA 92253 --
Contractor:
OWNER BUILD
Llc. No.:
3/19/2019
r
L� L
C)
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.
Sec29I have and will maintain workers' compensation insurance, as required by
700 of the Labor Code, for the performance of the work for which this permit
is issued. My workers' compensation insurance carrier and policy number are:
Carrier: Policy Number:
shalftI certify that in the performance of the work for which this permit is issued, I
. mploy 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: AlApplicant _ ' AA im-1
WARNING: FAILURE TO SECURE WORKeWCOMPf4150ION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
Date:iV
Signature (Applicant or Agent
Date: 3/19/2019
Application Number:
Property Address:
APN:
Application Description
Property Zoning:
Application Valuation:
Applicant:
GIRARDIN, GERI
51830 AVENIDA MORALES
LA QUINTA, CA 92253
BRES2019-0076
51830 AVENIDA MORALES
773152004
CHANGE OUT (8)WINDOWS
$1,000.00
Owner:
GIRARDIN, GERI & ROBERT
51830 AVENIDA MORALES
LA QUINTA, CA 92253
Contractor.
OWNER BUILD
Llc. No.:
Detail: CHANGE OUT (8)WINDOWS (2)MADE SMALLER BUT STILL COMPLY WITH 2O16 CALIFORNIA BUILDING CODES.
78-495 CALLE TAMPICO T4ht D e4qw 094a VOICE (760) 777-7125
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
DESIGN & DEVELOPMENT DEPARTMENT INSPECTIONS (760) 777-7153
BUILDING PERMIT
Date: 3/19/2019
Permit Type/Subtype:
BUILDING RESIDENTIAL/REMODEL
Owner:
Application Number:
BRES2019-0076
GIRARDIN, GERI & ROBERT
Property Address:
51830 AVENIDA MORALES
51830 AVENIDA MORALES
APN:
773152004
LA QUINTA, CA 92253
Application Description:
CHANGE OUT (8)WINDOWS
C
Property Zoning:
Q
N
Application Valuation:
$1,000.00
o�
Applicant:
Contractor:
GIRARDIN, GERI
OWNER BUILD
51830 AVENIDA MORALES
LA QUINTA, CA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter
9 {commencing with Section 70001 of Division 3 of the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.:
Date:
Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division
3 of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).:
(_) 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 and Professions Code: The Contractors' State License Law does not
apply to an owner of property who builds or improves thereon, and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden of proving that
he or she did not build or improve for the purpose of sale.).
I) I, as owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves
thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
(_) I am exempt under Sec. . B.&P.C. for this reason
Date:
Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
Llc. No.:
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 and policy number are:
Carrier: Policy Number:
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:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the Building Official for a permit subject to
the conditions and restrictions set forth on this 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 application , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
Date: Signature (Applicant or Agent):
Date: 3/19/2019
Application Number:
Property Address:
APN:
Application Description
Property Zoning:
Application Valuation:
Applicant:
GIRARDIN, GERI
51830 AVENIDA MORALES
LA QUINTA, CA 92253
BRES2019-0076
51830 AVENIDA MORALES
773152004
CHANGE OUT (8)WINDOWS
$1,000.00
Owner:
GIRARDIN, GERI & ROBERT
51830 AVENIDA MORALES
LA QUINTA, CA 92253
Contractor:
OWNER BUILD
Llc. No.:
Detail: CHANGE OUT (8)WINDOWS (2)MADE SMALLER BUT STILL COMPLY WITH 2O16 CALIFORNIA BUILDING CODES.
DESCRIPTION
ACCOUNT QTY
PERMIT ISSUANCE
101-0000-42404 0
Total Paid for PERMIT ISSUANCE:
DESCRIPTION
ACCOUNT
CITY
RECORDS MANAGEMENT FEE - MAJOR
101-0000-42416
0
Total Paid for RECORDS MANAGEMENT FEE - MAJOR:
DESCRIPTION
ACCOUNT
QTY
TECHNOLOGY ENHANCEMENT FEE
502-0000-43611
0
Total Paid for TECHNOLOGY ENHANCEMENT FEE:
DESCRIPTION
ACCOUNT
QTY
DOOR/WINDOW, RETRO/REPAIR, EA ADDITION 5
101-0000-42400
0
DESCRIPTION
ACCOUNT
QTY
DOOR/WINDOW, RETRO/REPAIR, FIRST 7
101-0000-42400
0
Total Paid for WINDOW/SLIDING GLASS DOOR/FENESTRATION:
AMOUNT
$101.40
$101.40
AMOUNT
$21.00
$21.00
AMOUNT
$5.00
$5.00
AMOUNT
$11.21
AMOUNT
$67.24
$78.45
/ I I
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
Considering Becoming an Owner -Builder?
Important information you need to know BEFORE pulling your permit!
The term "Owner -Builder" can mean three different things:
"Owner as Worker", "Owner as Contractor" or "Owner as Employer"
Understand each has Benefits or Risk, and it is possible to combine them!
Hiring a California Licensed Contractor means you do not personally perform any of the construction work, the permit is not taken
out in your name, you are not personally responsible for the construction and you are not an Owner -Builder. Instead, you become a
"Customer" and California law provides you the benefit of protection from poor workmanship, failure to finish the job and financial
risk due to worker injury.
Benefit/Risk: Ili hest Benefits and the Least amount of Risk
Owner -as -Worker is a type of Owner -Builder where you personally perform the construction work, the permit is taken out in your
name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You
benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully.
Benefit/Risk: Possible Benefit with Low Financial Risk
Owner -as -Contractor is a type of Owner -Builder where you personally act as your own General Contractor, the permit is taken out in
your name and you hire California licensed sub -contractors to perform portions of the construction work. WARNING; The benefit of
protection provided by law when you hire only California licensed sub -contractors can turn to serious financial risk if you hire
unlicensed contractors to perform any of the work.
Benefit/Risk: Possible Benefit and Sianificant Financial Risk
Owner -as -Employer is a type of Owner -Builder where you pay any unlicensed individual to perform any construction work valued at
more than $500.00, the permit is taken out in your name and you are personally responsible for their employment requirements,
supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial
risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker.
Benefit/Risk: Possible Benefit with Significant Financial Risk
(Health and Safety Code Section 19827) The California Legislature declares an "urgent and statewide
public interest in assuring" that contractors comply with Contractors' License Law, Business and
Professions Code and Workers' Compensation Insurance requirements to ensure property owners are
informed about, and protected from the following when improving their property as Owner -Builders:
Fraudulent representations • Liability for worker's injuries • Liability for material and labor costs unpaid by
contractors - Licensing requirements • Employers tax liabilities
Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects
and include workmanship and workers' compensation issues Homeowners suffer financial harm due to
defective workmanship and injured employees.
Following are alarming examples of what has occurred with Owner -Builder permits:
Example 1: Homeowner received insurance money to rebuild burned -down home.
• Owner/Builder permit pulled to rebuild structure.
• Unlicensed contractor built substandard structure — must be torn down and replaced.
• Estimated financial injury is $225,000.
• Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of
the year.
Example 2: Brother-in-law had active license but filed an exemption from Workers Comp.
• Owner -Builder hires brother-in-law to install a new roof.
• Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and
remains in a coma to this day.
• The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for
benefits paid to the injured worker.
Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic
system and suffers injury that results in permanent disability.
The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit
a claim.
• The Owner -Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured
worker.
Did you know — unlicensed persons frequently have the property owner obtain an "Owner -Builder" building
permit which erroneously implies that the property owner is providing his or her own labor and material
personally?
Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your
property by an unlicensed contractor and his/her employees?
Did you know — if you are considered an "employer" under state and federal law, you must register with
the state and federal government, withhold payroll taxes, provide workers compensation and disability
insurance and contribute to unemployment compensation for each "employee"?
Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk?
OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR
YOUR CONSTRUCTION PERMIT
Tiat 4 4 a"
P.O. Box 1504
LA QUINTA, CALIFORNIA 92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY OWNER'S PACKAGE
(760)777-7012
FAX (760) 777-7011
Disclosures & Forms for Owner -Builders Applying for Construction Permits
IMPORTANT! NOTICE TO PROPERTY OWNER
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the roperty
improvements specified at f k A q� 53
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your
responsibilities and possible risk you may incur by having this permit issued in your name as the
Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,
signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice
unless you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
DIRECTIONS: Read and initial each statement below to signify you understand or verify this information.
A1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
( ding permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as
an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
on my property.
d, I understand building permits are not required to be signed by property owners unless they are responsible for the
iction and are not hiring a licensed Contractor to assume this responsibility.
iI understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
f from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
e2k4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
is and contracts.
A5E5, I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
y construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"
under state and federal law.
jgfr6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal
rrunent, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment
compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
a7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
ttures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
�8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any
tTr*ncial ar personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the
workmanship or materials.
1i9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue
ce, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at I
800-321•CSLB (2752) or www.cslb,co.gov for more information about licensed contractors.
�y10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
legall and financially responsible for proposed construction actIvt� at the following address:
A I
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all
able laws and requirements that govem Owner -Builders as well as employers.
12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I
provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with
someone who does not have a Iiense, the Contractors' State License Board may be unable to assist you with any financial loss
You may sustain as a result of a complaint, Your only remedy against unlicensed Contractors may be in civil court. It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working
on your property, you may be held liable for damages. If you obtain a pen -nit as Owner -Builder and wish to hire Contractors,
you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'
compensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuing the permit. Note. A COPY Of the property owner's driver's license, form notarization, or
Other verification acceptable to the agency is required to be presented when the permit is issued to verify the property
owner's signature.
Signature of property owner Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
eku r t;vMLZ-A 1-MA Uk' AGENT TO ACT ON PROPERTY OWNS ' F
Excluding the Notice to Property Owner, the execution of which I understand is my pe responsibility, I hereby authorize
the following person(s) to act as my agent(s) to apply for, sign, and file the doc E necessary to obtain an Owner -Builder
Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perj that I am the property owner for the address listed above and I personally filled out the above
information and certify its curacy. Note: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agen is required to be presented when the permit is issued to verify the property owner's signature.
Property Owner>,�Signature: Date:
ta
� -
� . 6j
PERMIT #
PLAN LOCATION:
Project Address: 5/S-30
Project Description:
APN #:
WlwboKl EF1.AaEMEEA-r (9)
Applicant Name: <:4E-Z2% .4iFQ4,R1]JAI
Address: 5/030 Mop,4LE S
City, ST, Zip: VWTAI CA IRQ53
Telephone:
Email:
Valuation of Project $ / 000. t-o
Contractor Name:
New SFD Construction:
Address:
Conditioned Space SF
City, St, Zip
Garage SF
Telephone:
Patio/Porch .SF
Email:
Fire Sprinklers SF
State Lic: City Bus Lic:
Architect/Engineer Name:
Construction Occupancy:
Address:
Grading:
City, St, Zip
Telephone:
Bedrooms:
Stories:
# Units:
Email:
State Lic: City Bus Lic:
�1�
Property Owner's Name: /14j'ov
New Commercial / Tenant Improvements:
Address: SIS310
Total Building SF
City, ST, ZipLA 9011,17-A a7a1<53
Construction Type: Occupancy:
Telephone:
Email: /.
I-J 78495 CALLE TAMPICO
LA QUINTA, CA 92253
760-777-7000
OFFICE USE ONLY
#
Submittal
Required
Received
Plan Sets
Structural Calcs
Truss Calcs
j
Title 24 Calcs
Soils Report
Grading Plan (PM10)
Landscape Plan
Subcontractor List
Grant Deed
HOA Approval
School Fees
Burrtec Debris Plan
Planning approval
Public Works approval
Fire approval
City Business License
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTI9N
Jo "
/-, � 0
D
MAR 19 2019
CITY OF LAQUINTA
DESIGN & DEVELOPMENT DEPARTMENT w
MEETS 8,�RooM E-GRE55 c,�viR M �I'rS
CITY OF LA QUINTA SL! -CONY CTOR LIST
JOB ADDRESS;;� PERMIT NUMBEF� 2-DIl" tWNER
BUILDER d-Ok55�'�
_
This form shall be.Posted on the job with the Building Inspection Card at all —times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to comrriencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade..j Classification C,o.ptraetor State Contraotors .-Li.eensb.... _. W..o.rkers.Cornp.ensation, Insurance . City.B.usiness L cease
Company Name Classification License Number Exp. Date Carrier Name Policy Number Exp. Date License Number Exp. Date
(e.g. A, B, C-8) (xxxxxx) (xx/r,x/xx) (e.g. State Fund, CalComp) (Format Varies) (xx/xx/xx) (xxxx) (xx/xx/xx)
EARTHWORK (C=72)
CONCRETE {C=8)
FRAMING {.C-5)
STRUGT. STMI. (C-59') -
MAsoNRY (C-29.)
PLUMBING (C-3.6)
LATH., PLASTER (C135)
DRYWALL (C 91.
HVAC (C-20)
ELECTRICAL
ROOFING(C-39)
SHEET METAL (C-43)
FLOORING (C-1.5)
GLAZING. (0-17)
INSt1LATION (C-21
.SEWAGE DISP. (C-42)
PAINTING: (C-33)
CERAMIC TILE: (.C-54)
CABINETS (C-6)
FEN.O.NG (:C=1.;3)
LAN D:S:CAPING f.C-27).
POOL (.C=531
STATE OF CALIFORN!1
Prescriptive Residential Alterations
CEC-CF1 R-ALT-a5•E (Revised 04116)'
CERTIFICATE OF COMPLIANCE
Prescriptive Residentia
That Do Not Require HERS Field Verification
rations That Do Not Require HERS Field Verification
i�
OMMISSION
CFIR-ALT-05-E
Page 1 of 4
This compliance document is only applicable to simple alterations that do not require HERS verification for compliance. When HERS verification is required, a CFIR-ALT- 01 shall first be registered
with a HERS Provider Data Registry.
Alterations to Space Conditioning Systems that are exemptfrom HERS verification requirements may use the CF1R-ALT-05 and CF2R-ALT-05 Compliance Documents. Possible exemptions from duct
l leakage testing include: less than 40 ft of ducts were added or repld'ced; or the existing duct system was insulated with asbestos; or the existing duct system was previously tested and passed by a
I HERS Rater. If space conditioning systems are altered and are not exempt from HERS verification, then a CF1R-ALT-02 must be completed and registered with a HERS Provider Data Registry.
Alterations that utilize close Cell Spray Polyurethane Foam (ccSPF) with a density of 1.5 to less than 2.5 pounds per cubic foot having an R-value other than 5.8 per inch, or Open Cell Spray
Polyurethane Foam (ocSPF) with a density cf 0.4 to less than 1.5 pounds per cubic foot having an R-value of 3.6 per inch, shall complete and register a CFIR-ALT-01 with a HERS Provider Data
Registry.
If more than one person has responsibility for installation of the items on this certificate, each person shall prepare and sign a certificate applicable to the portion of construction for.which they are
responsible. Alternatively, the person with chief responsibility for construction shall prepare and sign this certificate for the entire construction. All applicable Mandatory Measures shall be met.
Temporary labels shall not be removed before verification by the building inspector.
A. General Information
01
Project Name'
�W E1P (`r�ME��
02
Date Prepared:
03
Project Location:
�1 S�0 MO UTAIT �k gaaS3
04
Building Front Orientation (deg or cardinal):
OS
CA City:
06
Number of Altered Dwelling Units:
07
Zip Code:
08
Fuel Type:
09
Climate Zone:
p
10
Total Conditioned Floor Area (ftZ):
11
Building Type:
12
Slab Area (ft)
13
Project Scope (Select all that apply):'
❑ B. Insulation 0✓ D. & E. Fenestration/Glazing - ADD
❑ C. Roof Replacement ❑ D. & F. Fenestration/Glazing -
❑ G. Space Conditioning System (Heating, Cooling, Duct system) ❑ Lighting
REPLACE ❑ H. Water Heating System ❑ Include Mandatory Measures?
CA Building Energy Efficiency Standards - 2016 Residential Compliance April 2016
STATE OF CALIFORNIA
Prescrintivre Residential Alterations That Do Not Require HERS Field Verification
❑1
C EC-CF 1 R-A LT-05-E (Revised 04/16) _ CALIFORNIA ENERGY COMMISSIOP
CERTIFICATE OF COMPLIANCE MR-ALT-05-E
Prescriptive Residential Alterations That Do Not Require HERS Field Verification Page 2 of 4,
Project Name: lax flmPa`d'
D. Fenestration/Glazing Allowed Areas and Efficiencies (Section 150.2(b)1)
01 02 03 04 0S 06
Maximum
Maximum
Existing
'
'a07
-M4 DOw5 MEAT SILL
i�]N
Allowed
Allowed
Fenestration
Existing
MaRimum
Maxi
Maxirslum
Maxi
Hre�rrf-TUi [ZIY��ITs
Fenestration
West -Facing
for All
West -Facing
Allowed
All ed
Allowed
All ed
m�
Alteration
for Ali
Fenestration
Orientations
Fenestration
U Factor
-Factor
SHGC
HGC
��
li;{��SEmrr0j�y
Type
Orientations (ftz)
Area Only (ftZ)
(ftZ)
Area (ftZ)
(Windows)
Skylights)
(Windows)
_ Skylights}
79,Ta_-DWEd
•a9
1
a3
6% P,=j_r_A- , Qf .aa
E. Fenestration Proposed Areas and Efficiencies - Add (Section 150.2(b)1A)
01
02
03
04
0S
06
07
08
09
10
11
12
13
14
Tag/ID
Fenestration
Type
Frame Type
Dynamic
Glazing
Orientation
(N, S, W, E)
Number
of Panes
Proposed
Fenestration
Area (ftz)
Proposed
West Facing
Fenestration
Area (ftz)
Proposed
U-factor
Source
Proposed
-SHGC
Source
Exterior
Shading Device
Combined
SHGC from
CF1R-ENV-03
t
w
Delete Raw
4
1SlCootmtpliancAeStdatement
Fenestration Area
16ed
Fenestration Area
17
ITotal Proposed Fenestration Area <_ Maximum Allowed Fenestration Area
r Yes
i` No
18
Total Proposed West -Facing Fenestration Area
19
Maximum Allowed West -Facing Fenestration Area
20
Compliance Statement
Total Proposed West -Facing Fenestration Area <_ Maximum Allowed West -Facing Fenestration Area
Yes
e+ No
21
Proposed Fenestration U-factor (Windows)
22
Required Fenestration U-factor (Windows)
23
Compliance Statement
Proposed Fenestration U-factor _< Required Fenestration U-factor
r; Yes
r No
24
jProposed Fenestration SHGC (Windows)
CA Building Energy Efficiency Standards - 2016 Residential Compliance April 2016
STATE OF CALIF^RNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
r,rr,_e'r1 0_41 r— a ■o....:._� none.
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Field Ve
ERGY
CF1R-ALT-05
Page 3 of 4
CA' Building Energy Efficiency Standards - 2016 Residential Compliance
April 2016
STATE OF CALIFORNIA
Prescriptive Residential Alterations That Do Not Require HERS Field Verification
CEC-CF1 R-ALT-05-E tRevised 04116)
CERTIFICATE OF COMPLIANCE
Prescriptive Residential Alterations That Do Not Require HERS Fie d Verification
P..iets Name: 5 _ _ i. _.. T T7 �+r� � /i w r —F~
DOCUMENTATION AUTHOR'S DECLARATION STATEMENT
1. 1 certify that this Certificate of Compliance documentation is accurate and complete.
❑ecument! 11th0r Name: r - , - r Documenta uthur signatyrg;
1 / �irlli. 1i--
I / - I Q/ V +sue-.+ s
RESPONSIBLE PERSON'S DEC RATION STATEMENT
Pre
CALI
COMMISSION
CF1R-ALT-05-E
Page 4 of 4
I certify the following under penalty of perjury, under the laws of the State of California:
1. The information provided on this Certificate of Compliance is true and correct.
2. 1 am eligible under Division 3 of the Business and Professions Code to accept responsibility for the building design or system design identified on this Certificate of Compliance (responsible
designer).
3. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of
Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the California Code of Regulations.
4. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents,
worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application.
5. 1 will ensure that a registered copy of this Certificate of Compliance shall be made available with the building permit(s) issued for the building, and made available to the enforcement agency
for all applicable inspections. I understand that a registered copy of this Certificate of Compliance is required to be included with the documentation the builder provides to the building
owner at occupancy.
Responsible igner Name: Respansih[e D r Signature-
�/925C?
/Zip-
- r1 r
r
For assistance or questions regarding=*e Energy Standards, contact the Energy Hotline at: 1-800-772-3300.
r
CA Building Energy Efficiency Standards - 2016 Residential Compliance April 2016