SFD (0304-271)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
652901 I3 12x)11 /NC
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&RC. 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.
k/) I have and will maintain workers' compensation insurance, as required by
S.ec ion 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 STATE FUND Policy No. 239- 00197'1 7.2003
(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 'p . rovisions of Section 3700 of the Labor
Code, I shall forthwith comply.with thosprovisions. /'l
8'ate: 5"- ? �- r/z Applicant ,r^,' r� ,1 7 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) '-.�`� ! -'` Date _''d +•U�'•
A �
k.t
• "BUILDING PERMIT PERMIT# • - .
DATE VALUATION LOT Q304-271 TRACT
9S%494,00
JOB SITE
ADDRESS e4.��-r.i�i) A N�.}�G�d�
APN
77 �i-�i�� �'�
OWNER
CONTRACTOR/ DESIGNER/ EN IINEEER
17HOMAS ByryTM ..
4dyamn>n
tv,0, BOX 134
41.160H M1!'1'AGEAR
LAQtMUA CA. 922"S3
MRMUDA:13tTMOR ' CA 92201
(760)MU-7525 MIX V24
USE OF PERMIT
f
somai 211, FA3vll: Y i TT 1 't3 J
1436 SY. SILO PERIUCIT D01?.S NOT INCLUDE 81.f CK WAL4, POOL OR
DRIVEWAY APPROACH
TRACT CONSTRUCTION 1,436.00 SA
PORCHMAT10 144.0 SP '
OARAWCARPORT 400-00 SF
•• EMUNM C;It3W OF Ct1ATS,i'IUCT10N
JJ''��QQ//��j �j �4
COl 0TRUCTION 'FAR 101.000-418.000 $MAJO ,
PLAN i;I- cr. PPIX $494.33
RE .DEPOSIT 101-000-439-318 $3SO.9A
I I4CCIiR2afCAI. P1?I8 1017000-421,000 $63.60 .
ILECTIiYM PEE 101-000-420.000 21031% '
PLUMBINGFEE .' 101-000-419-0.00 $138.00
STi1.4?1`lCl MOT.1014 FEE - Ik SK) 101.000.241 *.1100
DRADINC#IEElfllO f-42,3-000
DEVELOPRIZ MPACT IES
d'RWISIF PLAN 101-000-44,1-345 $ioo.00 '
'} 01�T, R UC TdO;U f�AM Flw�l�o1' CI,"
$3,897.34
3 , 1XV81j>�PA1D FVE3
-$250,00
MAY 4 3
iTV OF LA QEINTA
FINARt
RECEIPT
DATE ' 4
BY ,
DATE FINALED
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
off
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
/��
Combustion Air
Roof Deck
/_ p
Exhaust Fans
O.K to Wrap
Framing
- G
F.A.U.
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 �.
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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
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 (r /.5 0
Final
Utility Notice (Perm)
COMMENTS:
A
CERTIFICATE OF .COMPLIANCE vFs�
Desert Sands Unified School District
47950 Dune Palms Road
/� q Q BERMUDA DUNES r
Date 5/22/003 La Quanta, CA 9A225) Cn RANCHO MIRAGE 0
No. 24448 (76�) 77795 1 5 �� INDIAN WELLS ti
PALM DESERT 1
LA QUINTA
O YJ
Owner Thomas Buffin APN # 774-063-004
Address P. O. Box 134 Jurisdiction La Quinta
City La Quinta _ Zip 92253 Permit # 0304-271
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # : No. Street S.F.
,Unit 1 53080 " 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 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 1,436 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 CCNalley Independent Bank - David Addington, check No. 287202
Name on the check Telephone 760/408-7528
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by S" MCGilvrey $3,073.04 $o.00
Payment Recd Over/Under
W
Signature /-0
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90-day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - ApplicanVReceipt Copy.- Accounting
DCT -17-2003 07:03 AM
P. 02
CERTIFICATE OF FIELD 'VERIFICATION AND DIAGNOSTIC TESTING CF -4k
Project Title,.v patsg
Proj t Ad ress Builder Name
86iider Cont ct Telephone Pian Number
'$
HER ater Telephone Sample Group Number
VI
tifying Signature to Sample House Number
Firm:HERS Provider,G,�-/lS�BG/�Cs
Z41 0-k n a
Street Address: 7 Ara y atyistatelzlp:CA
Copes to: Builder, HERS Provider
HERS RATER CO IANCE STATF-MJNJ
Tine house was, Tested 0 Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, 1 certify that the houses identified on this form
co ly with the diagnostic, e
,sted compliance requirements as checked on this form,
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 7.5
If fan flow is calculated as 400cfmlton x number of tons enter /
here
calculated value
If fan flow is measured enter measured value here
1 /
Leakage Percentage (100 x Test LeakagelFan Flow) _ �• 1/ /r�
Check Box for Pass or Fail (Pass=6% or less)
❑
Pass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
�1 Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access is provided for inspection
(�''� ❑
Yes is a pass
Pass Faii
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN CQMPLIANCE CREDIT
i ❑ Yes Q No RCCA Manual D Design requirements have been met
(rater has verified that actual Installation matches values in
CF -IR and design on plan,
2. ❑ Yes O 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
Q ❑
Yes for both 1 and 2 is a Pass
Pass Fail
0
JUL 013 '03 15:05 FR TO 9-7777011 P.02iO3
vToBuild Ori
Engineerfng • Co»sidting • T�sNng -
REPORT OF FIELD COMPACTION TESTS
TESTED FOR: DAVE ATTXNG'TON PROJECT: 53080 AVE ME=OZA
POWER FINANCE LA QUINrA, CA
PO BOX 134
LA QUINTA, CA 92253
)ATE:
June 25, 2003
OUR REPORT NO.: 073-30245-2
rESTDATA:
(1) Grayish brown
silty sand
w/, fine
to Coarse sz:nd & small
cobble_ OPT. MOIST. = 11-
1_......._......-..
...... ..... .. . .
MAXIMUM
COMMENTS,
TEST
TEST
SOIL 10
LAO DRY w
WATER
WE
DRY
PERCENT
`� ec 90$ Min
p
NO,
DEPTH
- ELEVATION
NUMBER
DENSITY
CONTENT
DENS TY
DENSITY
COMPACTION
1
8"
FG
1
126.0
7.8
127.7
118.5
94-0
1 - A
2
$"
i. FG
1
126.0
8.6
12E;.4
116.4~
92.4
1 - A
3
811
FG
I 1
126.0
6.8
12'_4
119.3
94.7
1 - A
FG
( 1
'126 -01
8-2
130.22
( 120.3
9-5_5--
7 - A
4
811
rESTLOCATION: Building pad finish grade -- 53080 Ave Mendoza
1 SW end, within building line
2 NE end, within building line
3 SE end, within building line
4 Center of pad
--........ .,1... ---- --........ -- -- , ......--.-- -- I
40TES: TESTS PERFORMED PER ASTM D2922-96 & ASTM 03017-96 `COMMENTS: 1. FILL MATERI>L • A. TEST RESU4TS COMPLY IMTH SPECIFICATIONS
DENSITIES SHOWN Lbs, per cubic foot 2. 8AC 1(FILL B. PERCENT COMPACTION DOES NOT COMPLY
WATER CONTENT: Percent of dry weight, 3. BA5E COUR:i' .WITH SPECIFICATIONS
PERCENT COMPACTION: Based on maximum dry 4. SUBBASE C. RETgST O PR��VVIQ TEST
den 12 obtelned on sample indicated by S. SOIL CEMENT D, MQISTUR IN EXCE �OF SPECIFICATIONS
soil ID numoer, 6. OTHER E. MVOISsTUR BELOW PECIFICATIONS
I* (1) ASTM D1557-00 METHOA A
TEST INSTRUMENT: STANDARD COUNT M: D;
REMARKS: PSI did not monitor the material placement. ADJUSTMENT DATA M: D:
Respectfully submitted,
TECHNI&AN: Vicki Drover. Professional Service Industries, Inc.
?-ESE TEST RESULTS APPLY ONLY TO THE SPECIFIC LOCATIONS NOTED AND MAY NOT REPRESENT ANY OTHER LOCATIONS OR ELEVATION$,
ZEPORTS MAY NOT aE REPRODUCED, EXCEPT IN FULL, WITHOUT WRITTEN PERMISSION BY PROFESSIONAL SERVICE INDUSTRIES, INC.
Professional Service Industries, Inc. • 42-240 Green Way, Suite C • Palm Desert, CA 92211 *'Phone 760/341-5790 • Fax 760/341-5794
'su.,00-z 141F
JUL 08 '03 15:06 FR
AM AMU.-Wo
Infonnatzvn
� Build On
Engineering - Comuffing • TesoM
REPORT OF FIELD COMPACTIOhl TESTS
TESTED FOR: DAVE ATTINGTON PROJECT: 53060 ,AVE MENDOZA
POWER FINANCE SQA. QUINTA, CA
PO BOX 134
LA QUINTA, CA 92253
DATE: June 25, 2003 OUR REPORT NC.: 073-30244-2
TEST DATA: (1) Grayish brown silty sand w/ fine to coarse sand. & small cobble. OPT. MOIST. 11.
TEST
NO.
1
TEST
DEPTH —
B"
ELEVATION
SOIL ID
NUMBER
MAXIMUM
LAB DRY +
DENSITY
WATER
CONTENT
'WET
OENSRY
DRY
DENSITY
124.5
PERCENT
COMPACTION
98.8
COMMENTS'
Spec. 90$ Min
1 - A — _--
1
I 1
! 126Y0:
I1111
126.0
— (;-4 —
13:3__ 5
2
---
8"
-FG--_-- _
FG
6.5
13_.7
123.7
98.2
1 - A
3
$"
FG
120.8
95.9
1 - A
1
if 126.0
7.2
12:1-5
$"
FG
1
—
126.0
94.8
1 - A
4
6.6
12.1.4
119.5
TEST LOCATION: Building pad finish grade -- 53060 Ave Mendoza
1 SE and, within building line
2 NW end, within building line
3 SW end, withing building line
4 Center of pad
VOTES: TESTS PERFORMED PER ASTM D2922.96 & ASTM D=7.96 'COMMENTS 1. FILL MATERIAL A. TEST REST g,$ COMPLY WITH SPECIFICATIONS
DENSITIES SHOWN: Lbs. per Cubic foot 2. BACKFILL B. PERCENT c` MPACTION DOES NOT COMPLY
WATER CONTENT; Percent of dry -eight • $, COURSE WITH SPECIFICATIONS
PERCENT CO�t�yyMPACTION; gas on maximum dry 4. SU�BASE C. REEpT$$ES�T�JJ OF PREVIOUS TEST
soil IOrnubn b.ed on Semple Indicated by 6. OTHCEMENT E, INOI$TL1RE BELOW SPECIFICATIONS TIONS
* (1) ASTM D1557-00 METHOD A
TEST INSTRUMENT: STANDARD COUNT M: D:
REMARKS: PSI did not monitor the material placement- ADJUSTMENT DATA M: D:
TECHNICIAN: Vicki Dro'v'er
rHESE TEST RESULTS APPLY ONLY TO THE SP[CITlC LOCATIONS NOTED AND MAY NOT REPRESENT ANY OTHER LOCATIONS.OA CLEVATiONS,
KPORTS MAY NOT BE REPRODUCED. EXCEPT IN PVLL. WITHOUT WRITTEN PERMISSION BY PROFESSIONAL SERVICE INDUSTRIES. INC.
Respectfully submitted,
Professional Service Industries, Inc.
'SIA -10a2 (41F Professional Service Industries, Inc, • 42.240 Green way, Suite C • Palm Desert, CA 92211 -Phone 760/3,11.5790 - Fax 760/341-5794
** TOTAL PAGE.03 **
�- Caertifka to of Occupancy
Asa
5
OF9w Building & Safety Department
This Certificate is issued pursuant to the. requirements of Section 109 of the California Building.
Code, certifying that,, at, 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: 53-080 AVENIDA MENDOZA
Use classification,: SINGLE FAMILY DWELLING ;Building. Permit No.: 0304-271
Occupancy Group:.R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: THOMAS BUFFIN Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA, CA 92253
!-ate By. KIRK KIRKLAND
Date: NOVEMBER 24, 2003
Building Official
POST IN A CONSPICUOUS PLACE