0212-040 (SFD)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
6n, 901 1:3 l?6'.11/2(
Date 4 S'�r'+'2 Signature of Contractor—0 J-9 /' nZ ='
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).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
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 STATR FUND Policy No. 2"_ 001t%p"37-2003
(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: L— Applicant u^> > • %� �� -
./ e- d � o .✓ � /'y'Y 04'x, -
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 o'r;ins ection purposes.
Signature (Owner/Agent)_' ° `� ��a r Date /_ :. ✓:^4
BUILDING PERMIT PERMIT#
0212,040
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 151
OWNER
CONTRACTOR/DESIGNER/EN INEEW
VMIJAM 1311 !
DAV.M I- A17DR40710. 3
P.0 ,_.'.P 'Y 13
41-1801%RWffF.A 7,R DR
11! QUINT.& CA 92253
RE'Rab�tT9.A DUNKS CA
•
��j/�{2201 y / 1
(760)408-7526 4.v7.J.tR�' 3.Y 24
USE OF PERMIT
SINGLY TrA"my DWFJ_L1WG
SFl) - L T & PERMIT DOESNOT INCLUDEBLOCK WALLS, POCIA, SRA
OR DR1Vr,%1WY.fiA,AP1t0A0H. 15%i1&DUC: T IC?W TO KKR CHECK PEE FOR
MULTIPLE ISSUANCE OF SIAMEPLAN TYPE
TRACT C:O(HOTRUCTION 1,431.00 SF
POR.0 WPATIO V7.00 F
GARAC4Ef ARDOR T 487.0 3F
e
ESI'9'.1 ATJO) COST OF C:0X5rr&(7C'1' 01q
.
P.V,,,R14/ff FEE SUMMARY
c;ON3TRUCT1014 FFE 101-000-418-000 $590.00
PLAN CHECK FEE 101-000-439-318 $132.44
R-9 DEPOSIT 101.000.439-318 -22$0140
MECHAN,C:A.L. ►?ELr 101-000-421-000 $0.10
ELECTRICAL ME fill -000-420_000 $03,33
PL,UMErma IMEZ 101-000-419-000 $x122.75
�
.51T WHO M01''ON F''FE - RF.83ID 101-000.241.0.0 $9,95
ORADINICEE, 101-000-423-000 $15.00
DEVZ rCrPFR INIPA.C`l' FRE $2,405,00
-
PRECISE PIAN 101-000-441-345 $iQ0.00
1311:1-TOTA .. CC.3NSTR'ZTC" r10kT AO -M, IAN C>"ll:V'.l'
$3,:512.137
M.VfAL PYRNICU' '1 S 1.)'11'.
JAN .13 2003
CITY OF LA QUIN A
FINANCE DEPT.
RECEIPT
DATE A :'
BY
DAT A
INSP T
,,SS,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
J
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
iL C -
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor
Insulation
Fireplace P.L.
7'�U� �f'
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final-
•� _ _
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
/� – Q3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Cas Test
_
/.��j3
_
Encapsulation
Appliances
Final
COMMENTS:
-
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Wilily Notice (Perm) ��O'�
�1- 9a5 Avg D/G.,eEUon� �/
44-421 TOWNTHE ESCR0w'SOVRCF, INC.
.
MiN M WAY'..$L tm C; PALM.'DESERT; CA -02260-0000
(760) 776-4640 • Eau. (760) 776-4650
Escrow No.: 02-360343ASQ
Escrow Officer: SARA Qj1[1�PI'ERO
Dine: October 7, 2002
:E"6W sUAWARY: ,.
Broker;hiie on deposit for
eccoimi of buyer .
Buyer will deposit prior to close of'eearow
TOTAL, CONSIDEM17ON;
S 1.000.00
$ 42,500.00
$ 43,500.00
Escrow holder is instructed to close on or before November 21, 20p2.
T1TL'E/VEsriNo
Buyer to hand you aay:addiaorial
instrucrions her$in pbt8in aII and ins>runents access
Ctwners/ALTA Standard Covera a gp y for you to comPlY Kith
&•om ORANGE`COAST TI1'1:E with"their atandaid eicepuoilgs an Pro is°�f Title lns•,aaxtce
to have Ilabillty for eri .ainouryt riot to � eiceed $43;500 00:.
This policy is
proPertY� m the Couitry:of RiV,1LR.SIDE, State �f Cnliforcn' ' �riic policy is to 'be issued on real
. a, as follows:
PAI2GFd NT1 im 773-163-020
LOT e, BLOCK'&OF SANT.1,! CA1tM$LITA AT Ve►LE I.A,Q[J1N
RECORbEb W BOO 18, PACE SS.OB In, -VALE
OFFICE OF A' UNIT NO.2, AS,PBR MAR
RYV$RfiIDE COUNTY THE COUNTY RECORDER O_ F
Property Address: APN: 773-163420, LA QLTINTp; CA 92253'`
The title policy is to show the title,to the pr
9perty to be vested in:
M1C$ELLE EICHSTEDT
AND/ OR ASSIGNER
ENC UMS"N CES/EXCEPTIONS
The policy is to. be "frce of encumbrance except as follows:
(1) ane-al.and Special Taxes and:S` '
the lien of pedal L7lsmct Lcdies alit due or delinquent; this will° include
suppletnenfal;taxes, if $ny, essesaeti Ptiatit't Ch
State of Calif
orale o apter 498;.1983 "Statutes of the .
(2) Covenants, conditions, reservations (including ezceptioris ofoi
and/or lease without right of surface en h Bs, minerals' hYdiocarbons,
public utilities ;distzicts, water eoiil amesj'=rs fictions, rights of way, and easeatents for
(3) Assexsments.and bonds ofrecord,'ifany, not dolingiiea
INSTRUCTIONS
Tile 'Close fp
0 scr6W5shxll,ocaitr 45 da
escrow instructions 10 E Ys after accePtanee. Boyer and Seller:shell.delivtr signed
actow iiolder;w%ithih Wdays after aceopt
Each of "the nnAnei'...5 a t _
Califot iia Assernbl Bill. Wy .ac!
1990, hinds d Y Slz (need
aposltc'd :into escr+owi ;an
escrow by.the Property owner, Buyer c
cause a delay in.the close of escrow sill
the
;underslgned heteliy iin'demAM
es
understands iffat pursuant to State of
►n" )''which became effective January 1,
nth the title CoinPa,lY' for use in this
.Y foiili other'ihiin a wire tmnsfer may
of funds at the`t' " of closing. Each of
I ESCRO N SOURCE; INC.- and Its
ATTACHED HERETO AND MADE APART ]iEnois••
etaW he has read tJiOjoiBgofng. irurruciforiq and-de.,,d_dy tmd agne" t.,h,,
7 17
_ 1
i
r
Building).,,
Address s J
Owner (� L
h✓ fi r l � l lJ►/
Mailing
Address , 0, %3
( ifv 17in
L A 0a lAll-g,2 I
Contractor
?)/?1/(11 A
f- 7X0
TWit
P.O. BOX 1504
78-495 CALLE TAMPICO
�Ar-!.'&.YJNTA, CALIFORNIA 92253
/...
Tel.
a5 1 X
v GtmvtJA &At r -`W � o/ 740 - /_/Off - Sad
State Lic. City
& Classif. � gQ t . 43Lic. #
Arch., Engr.,
Designer
Address Tel.
City (Zip ( State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Diw'sion 3 of th//e?Business and Pro essions Code, and my license is in full force and
effect. % �Ls'trv4 r� t!4f„ •'� �t j am, 10
SIGNATURE ' DATE
OWNER-BUILDEfi DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior toils issuance also
requires the applicant for such permit to file a signed statement„that he is -licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (confinencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he 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).
L I, as oner 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, Buisness and
Professions Code: The Contractor's License Law•does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
,piovided that such 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 did not build or improve for the purpose of sale.)
1 1 I, as owner of the property, am exclusively contracting with I•icerieed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
doesnot apply to an owner of property who builds or improves thereon, land who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
i I I am exempt under Sec. 8. & P.C. for this reason *
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company '
Cl Copy is filed with -the city. • -O Certified copy is hereby furnished.
i
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.) h 1
I certify that in the performance of lhp work for which this permil'is issued, I shall not
employ any person in any manner so las to ecomesru subject to the Compensation
Laws of California. j !1/'
Date /' '�+�wrier,� fy✓ c_ p i
NOTICE TO APPLICANT., If, afar making this Ceiffihoate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for. 180 days.
1 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 the above-
mentioned property for inspection purposes.
Signature of applicant Date
flailing Address
City, State, Zip
WHITE = BUILDING DEPARTMENT
° �t1Nv;: .1,. ;; fj7 :.;d�{'G!}. a r�;•^c`:: w :�> Svc LL...�gc.. s.?+'r�:n-
T
APPLICATION ONLY
BUILDING: /
TYPE'C�ONST. W3` OCC.. GRP._
`
A.P. Number 1 -7� r `� c�)U
Legal Description
Project Description
w
Sq. Ft. .<%�/
Size J
No.
Stories
No. Dw.
Units
New �C Add ❑
Alter ❑
Repair ❑ Demolition ❑
r
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
7SJ�
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
;=
S.M.I.
i
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street,Setback from Center Line `
Side Setback from Property Line - \1
FINAL DATE lNqPrrTOR &A\i
Issued by: Date FPermit 11ll 1
Validated by: \1 t
Validation: nrr LAX
FINA9�CE
YELLOW = APPLICANT PINK =-FINANCE
Mai 08 03 08:53a David Barber
CERTIFICATE OF FIELD VERIFICATION AND
1 Project Title
'� 51-- y',�5 /
Projecj Address
Buil
3
G
T
illY�irYb�Z�L•�t
C TESTING
Builder Name
Plan Number
mple Group Number
rtifying Signature Dtfte Sample House Number
Firm: , 6. �'�%SSOG/%�gS HERS Provider: /�G-�f-%�S50G/4
Street Address: %y",q ff"d fay- Cl;;66, City/State/Zip:L 41
Copies to: Builder, HERS Provider
HERS RATER COMPLIANCE STATEMENT
The house was: Z 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 th
comply with the diagnostic tested compliance requirements asichecked on this form.
(� Distribution system is fully'ducted (i.e., does not use building cavities as plenums or platform returns
of ducts)
Where cloth backed, rubber adhesive duct tape Is installed, mastic and drawbands are used in comb
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)
Duct Pressurization Test Results (CFM @ 25 Pa)
Test Leakage Flow in CFM
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)
Z THERMOSTATIC EXPANSION VALVE I
i or Commission a
Measured
values
2
equivalent
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
Yes is a pass
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1. ❑ Yes ❑ No ACCA Manual D Design requirements have been met
(rater has verified that actual installatlon matches values in
CF -1R and design on plan.
2. ❑ 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 for both 1 and 2 is a Pass
"Pass
Pass
Pass
P.1
F-4 R
form
lieu
Fail
'Certificate -of Occupancy
City of La Quinta
Building and Safety D epartment
This Certificate issued -pursuant to the requirements:of Section 109.of the: Uniform Building Code,
,
ce. ifying.that, at the_aime of issuance, this structure'was in compliance with the various ordinances
of the, City -regulating building construction or `use: For the.; following:
BUILDING ADDRESS: 51-925 AUENIDA OBREGON
Use.Classification: SINGLE:FAMILY DWELLING Bldg.' Permit No.: 0212-040
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: WILLIAM BUFFIN
Building Official
Address: P.O. BOX 134
City: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: MAY 8, 2003
POST IN A CONSPICUOUS PLACE