SFD (0304-268)LICENSED CONTRACTOR DECLARATION
I.hereby affirm under penalty of perjury that I am licensed under provisions of
E' apter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lia Class ,f Exp. Date
Date i_ 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'fdr
sale (Sec. 70,44, 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 i}Ta<T.�1' p11pjI) . Policy No: x24- 00197"-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' 2 ? G " Applicant -„/ .��
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000; in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and. Safety
for a permit subject to the conditions and 'restrictions set ,forth on his
application.
,1. Each person upon whose behalf this application is made & eacli•person at r
whose request and for whose benefit work is performed under or pursuant to EL'
any permit issued as a result of this applicaton agrees. to, & shall, indemnity I
& hold harmless the City of La Quinta, its officers, agents and employees. U�
2. Any permit issued as a result of this application becomes null and void if �J
work is not commenced within 180 days from date of issuance of'such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property,for,inspection purposes.
Sigriature (Owner/Agent)---r - Date. C
.s,
-- -BUILDING PERMIT _ PERMIT#
DATE 'VALUATION LOT. 0304-2a TRACT
206
JOB SITE
APN
ADDRESS AypIM
773
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r
'iHf13± S T3UTTM ,,
L'rAVM(� 1��,.{AT,)DIi\gid IyD!}
yyyyyy
LA IMI CA” ! 2253
�SIz'�7�%TDA Dt Ml CA :+2201
!
060)408-.7528 CB;O 3'1-,4
USE OF PERMIT i.
SNC1IA RA13 ,Y l"_1WLYING
IAS6 S.F. SFD PERMIT HOES 1+10T Ji4CLUDE, '�1I, CK --'1A1..•4 POOL, OR _
iIR11�"I�+t'�,'�'..�PPROAC R '75% REDUCED Pl':AN CHECK RE FOR R+lili,i' PPE
P1.,ANS itE TYPE1 ► ;� t' `
TRACT CONSTRUCTION 1,436,00 SF
POiLS;i IPATIO i 97.00.SF
GaAI$At E(CARPOI'aT . - 400.00 SF
ErIM00) C05T0,_' C0H1YMtC1ja011
1110y73LE suhnimyA
CONSTRUCT ION' IEE 101-0004,18-000
PLAN CHECK FEW 101-000-439-31 & �i �Z.r3x7
ME DEPOSIT 101,,000-439.31.8 4230100
NIMCiiMUCAL F.M. 101-000-421-000 0 +21.59 "
I;L 4 T fi1CA;U.f'P.E .: 101.000420.000 • Islos.M ,
P U�li3illiQ'I P ? 101-000-419-000 $113,00
STRONG MOTION FEE - KMID 101.000-241.000 UZI
1(11-SDt`10-X23-0001
Lr■Ntq
q�1Sq.[1��0�
7��b�t.:[>'),DINa9I+I��, ry'r y
1. E ELOP R IR76L" kCA' S IS.'
PILtSCBwE PLAN 1.01-000441-345 $1c+t�.OiD
L am- t CON9SRU'G" 0141.F.ND]:71—W, .C%r9=.
$3,520.85
tMS FRE , -PAID FSES
..y
MAY 2 2:,"2003,
r TPTA#•r:1C lS b91fU ,+p'I"'Es t iiO`t�
CITY OF LA CdUINTA ` -
FINANCE nEPT.'
RECEIPT
DATE
BY
DA E FINALE
INSPEC R'
INSPECTION RECORD
f OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
G
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
G 3
Combustion Air
Roof Deck
Q
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
- 6 Y,
Compressor
Insulation
ijf
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 —
BLOCKWALL APPROVALS
POOLS - SPAS
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
Water Piping
—
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
7—/�
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 D S d
Final
Utility Notice (Perm)
COMMENTS:
CERTIFICATE OF COMPLIANCE ��FtEDSc
Desert Sands Unified School District 4�cS�o
47950 Dune Palms Road A
Q BERMUDA DUNES O
Cate 5/22/03 La Quinta, CA 92253 CA RANCHO MIRAGE d
_ INDIAN WELLS
No. 24447 (760) 771-8515 ,� PALM DESERT y
LA T
INDIOy��
Owner Thomas Buffin APN # 773-063-003
Address P. O. Box 134 Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0304-268
Tract # BLK 206 Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F." Lot # No. Street S.F.
Unit 1 22 53060 Avenida Mendoza 1436 Unit 6
Unit 2 Unit 7 =
Unit 3 Unit 8
Unit 4 Unit 9 ,
Unit 5 Unit 10 '
Comments -
At the present time, the Desert Sands Unified School District does not tolled 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 beendetermined 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 1,436 S.F. or $3,073.04 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/Valley Independent Bank - David Addington Check No. 287203 -
Name on the check Telephone 760/408-7528
Funding Residential
By Dr. Doris Wilson
Superintendent
.M
f
Fee collected /exempt d by S ron McGilvrey $3,073.04 $0.00..
' Payment Recd Over/Under
Signature C r`
NOTICE: Pursuant to Government Code Section 66020( 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 public 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 - Applicant/Receipt Copy - Accounting
OCT -17-2003 07:04 AM P.03
U
-au
Builder Name
Plan Number
Sample Group Number
Da Sample House Number
ing Signature
Firm: /
HERS Provider:
-71
SvW Address:
,�r:� oY I Citylstatelzip. G r
Copies to: euilder, HERS Provider
HE APER COMP IANC STATE E T
Tested ❑ Approved as part of sample testing, but was not tested
The house was:
As the HERS rater providing diagnostic tencerequirementsand
�as verification, onthis afohm.houses identified an this form
comp with the diagnostic tested compliance
L�8 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 (Maxlmum 6% Duct Leakage) Measured
'
Duct Pressurization Test Results (CFM @ 25 Pa) values
7"
Test Leakage Flow in CFM _
Test
1f fan flow is calculated as 400cfm/ton x numcalberoftons
hetes %
value
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)
❑
Pass Fail
i THERMOSTATIC EXPANSION VALVE XV or Commission approved equivalent
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
❑
equivalent) is installed and Access is provided for inspection
Yes Is a pass
Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1 0 Yes C] filo RCCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF•1 R and design on plan.
2. 0 Yes O No TXV is installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -11R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
s
Pass Fan
�a/10 Q•c
Ceififica to o.f Occupancyo
4
w
5
OF 9w Building &Safet enty Dep
artm
This Certificate is issued pursuant to the requirements of Section • 109 of the California Building
Code, certifying that, of the time, _ of issuance, this` structure was in compliance with the
provisions of the Building Code and the various ordinances of. the City, regulating building
construction and/or use.
BUILDING ADDRESS: 51'060 "ENIDA MENDOZA
Use classification: SINGLE; FAMILY DWELLING ": Building Permit No.: 0304-268
Occupancy Group: R3 Type of Construction: VN Land Use Zone: 'RC
Owner of Building THOMAS BOFFIN Address: P.O. BOX 134:
City; ST, ZIP: LA QUINTA, CA 92253
�.� By:' KIRK KIRKLAND
Date: November.6. 2003
.Building Official
'POST IN A CONSPICUOUS PLACE'