0206-220 (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
r'rofessionals Code, and my License is in full'force and effect.
License # Lic. Class Exp. Date
736920 a 4 � 11C►3
Date Signature of Contractor,., --
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:
Cartier STATE FUND Policy No. J"6408-200.7
(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: r�' i' - % .. 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.
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) Date' _
PERMIT#+ ;q
`
BUILDING
i 0'2220
• !
DATE i 'roc) VALUATION LOT TRACT 14LT.� 172JOB
SITE
ADDRESS ^ ,�Vl 1� ll�A C�I✓3J11� %K�i3
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
P,u.:I OXII 144
S 1374f
'tali,. QLT.IIv"fA CA 92253
LA QUINTA CIA, V iii .
�P�SQ}Sr�6 I4f3�: L 625
USE OF PERMIT
SWOLEY10ALY DWLLl LLD413
S1t'D, 1431 S.F. PPP_ 71T DOES NlOT .FNCI:.UDK P001,q BWC:K WALLS
OR CITY APPROACH
TRACT CONSTRUCTION 1,423.00 SW
•,
PORCI.11PATIO 33.10 SIS
CI.ARAOUCA PORT 300.114 OF
P.TE AM FET &T.L I.AAARY
CONSTRUCTION PER 101-000-418.000 %383150
PLAIN CHFCK FV,9 101-000-439-319
FEE DVOSIT 101-000.439.318 -42150.0
MECHANICAL 101-000-421.000
1':I.;KG" r11ICAL Ti`I E )01 -OW -420-000 1aI OU4
PLUMBING PEZ 101-000-419-000 $167.35
S T ROW1 MOTION FER - R4',OID 101.000.2414)00 $9.1A
0XA1"iIN0 M, 101-000-42-1-M) $15.0
�.
DEVELOPER IMPACT FEE
191tJJ ISY?•PLA.14 iUY-(1C)t1-4d.i-w1 fj �100.t�0
SUR -1" 01'AL' C' Oii :TWC ti ON A1+3:I:5.1ay,.,.A'TI' 6_"V X3?,'
1103 PRE. PAY) FEE&i
42,50',00. '
PEIZVirl, ZFES DUX 1401%,
CITY OF LA QUINTA .
FINANCE DEPT _
RECEIPT
DATE
BY
D FI/ryq D
INSPE R
Fi.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & FootingsDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—fJ
Exhaust Fans
O.K. to Wrap
j- _ �/
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final _ G _
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Bond Beam
!�
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-1 Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�, p
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole 0 - _ p
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power Q
Final
Utility Notice (Perm)
COMMENTS:
Building /
Address ^� 2, —:9, ¢, r)
Owner
Mailing
Address C-) • �l
City Zip
:r Contractor
Address
City Zip
uti 0_J
State Lie.
& Classif.�
Arch., Engr.,
Designer.
Address
City
I'�r. '43r.'$v`" •*,w�.VF7G„�$'t�P�,y Tri �+�,yi���,�:i4YiP„^Ci �. u�jY • i�Va ��5������I����Y�
y� t
P.O. BOX 1504 APPLICATION ONLY
/,)0 46-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92,253
BUILDING: TYPE'CONST. OCC. GRP.
3-. A.P. Number
Tel.
c 2 5 (o4 S 4 -IL-3 Legal Description L.,� "1 "�� t ke
Project Description ''� T� ^ I`
It
Tel..
22 .5 Co
City
r Lic. # Sq. Ft. No. No. Dw.
Size 2 1 Stories Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
Tel.
Zip (State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
SIGNATURE DATE
OWNER -BUILDER 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 toconstruct, alter, improve, demolish, or repair any structure, prior to its 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 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for
thealleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars ($500).
lJ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
buildsor improves thereon and who does such work himself or through his own employees,
,provided 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 licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & 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
. M Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate 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
I hereby 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 it work thereunder is suspended.for 180 days.
I certify that 1 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 sof this city to enter the above-
mentioned property for inspection purposes. -
Signature of applicant Date
Mailing Address
City, State, Zip
stimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
-
Plan Chk. Bal.,
Const.
Mech.
Electrical / m
Plumbing
a '
S.M.I.
Grading
Driveway En . Ill
e
-1/tv x
Infrastruct e
”) (;,J %
1"
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
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating -or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this -time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,421 S.F. or $3,040.94 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By CC VIB - Mark Kellog Check No. 2649:19
Name on the check Telephone 760/832.4641
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted b C stal Scott $3,040.94 $0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another publiic entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicarit/Receipt Copy - Accounting
CERTIFICATE OF COMPLIANCE
J FIED
Desert Sands Unified School District
c--:,-4 �o
47950 Dune Palms.Road
¢ BERMUDA DUNES r
Date
8/26/02
La Quinta CA 92253
rn RANCHO MIRAGE (�
INDIAN
No.
23522
(760) 771-8515
WELLSLM
��? PALA QUINTAT �y
�INDIO YJ
O
Owner
Thomas Buffin
APN #
773-315-007
Address
52880 Avenida Obregon
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit #
0206-220
Tract #
BLK173
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street
S.F. Lot # No.
Street S.F.
Unit 1 7
52880 Avenida Obregon 1421 Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments 2 Cashiers Checks
#264919 - $2913.05 and #264942 - $127.89
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating -or sanitation) or replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this -time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,421 S.F. or $3,040.94 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By CC VIB - Mark Kellog Check No. 2649:19
Name on the check Telephone 760/832.4641
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted b C stal Scott $3,040.94 $0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another publiic entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicarit/Receipt Copy - Accounting
OCT 23 182 13 23 FR TO 9-5686072 P.01i01
1
~V__.�oBuildOn
Information.. ; -
PM
M8ineeft • coesaltlny . Ttsffiv'
REPORT OF FIELD COMPACTION TESTS
"TESTED FOR_ :CONTFiMPORARy HOMES 'PROJECT. " '52-880 AVENIDA OBREGON
PO BOX 1041
LA 0UXN'TA• , CA 92253
SATE October 17, 2002 _ OUR REPORT NO.: 073-20266-2'
FEST DATA:' (1) Medium grained silty salad: OPT.:MOIST. .�, •8.0� .. -
TEST TE87' ►rINCIINIIM -- COmwM-
i NO. DEPTH SO210 ue DRY w WATEq WET DRY PERCENT g gC .
t;lEVaitppt NUMBER DENSITY CQW NT OENS17Y OENSr1Y: COMPAG`";4 • �� '90% Mirk
1 S" FG 1 120.0 6.2;;?.0..
-
��_ ;3.0 : 4 , 113. 4. 94.5 l - .A
2 8 -„ - SG 1: 120.0 123.,0,: 115 .'2'
96.0 1 - A
3 s �� i' .120.0 7_z - 12.0 '113:13 9: .8 1 A _.
4 8" FG 1 Y20. 7'2 119.0 111.0 ---
_.._ 92.5 1 - A
'ST LOCATION: House pad. "
1 6W corder:.
Z
SE' --Corner -- --..
NE 'comer
i �vw corner
1'E8: TUE37'S PER6�F�O�pRMED PER ASTM P2922-96, 8 ASTM. D3017.% *COMMENTS: 1, -FILL' MATERIAL A EST REB LTS COM Y yy~�}{ Sp�cIFIGAI IONS
ME
R CONTENT Parrpott or a�yweight 2- BACWLL B. CENT' PACTI DOES NOT COMPLY I
PENT COMP CTION: Based pn maYlmurn G•ry 3• eA¢HH COURSE C .R ST ENT OFfPFI T10N T
deE,tuyob med•an semDte indicated 4.°SU t3ASE pp (� p T
i sod ID nutn�v, by 5 OTHER 6. MOI i� BEL�tCIF1CA IFICATIONS f
(1) .ASTM 111557-00, METHOD A e: , ENS, .
'aT INSTRUMENT: STANDARD COUNT M, -D:
MARKS: PSI -did not ,monitor the• 'ma
•, 1 'material pFacem®nL . AD;IUS7MENT` DATA , •�, D. -
TECHNICIAN -
;TECHNICIAN: Juan NunezRespectfully submitted,
F PMfOSsiohe/ S&VICa Ind&&w4;`.1nC. I
;TEST AC"V D Ao?L,v OMLv TO 7w4 $VeC1PC LM^T10NS NOTED µD tMr IfOT A6FRf6iENTANY Of11iR LOCATIOIQm Ori aEVAT1ONtL
TO MY NOT BE Nt PRODUCED, ex CLOT iN 1 VLL- WIT/IOLR WRRTEN /UiM{S40T l BT /jtOiErAwy L 6611 Lo tmaw og E EvAT '
Processional servleo Industries, Inc- • 42-240 Green Way Suite C - Palin Desert, CA 82211 • Phor� 760%1:41-5790 - Fax. 7eDis41.-57®4
1/1 ' d-- ' Mg'ON :. HgZ-ti99 (090 SDOH AMOAIIN00 IV00:0 [ILZ00Z ' EZ' 100'
'Certificate of Occupancy
co
ity -of L.a Q. -pinta
r. S• fe t D e=
ad r�
B u�l din a�n:d_
This Certificate. issued pursuant to :the requirements of .Section 1 09. of-. the Uniform Building Code;
certifying fliat, at` the 6Me of issuance, .:this structuro was in. comp/lance with. the .various ordinances
of the City'regulating .building construction or use. For the following.'
BUILDING ADDRESS: 52-880 AVENIDA OBREGON
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0206-220
Occupancy Group: 113-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: THOMAS BUFFIN
Building Official
Address: P.O. BOX- 134.
City: '-LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: FEBRUARY 13, 2003
POST IN A CONSPICUOUS PLACE