0306-412 (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
fSate ? / 1 Signature of Contractor -'r¢-• �' - • ��'�`�`
f y
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
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 rof 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 a'!'1�,.;1�Y;, jtUND Policy No. 229- 001100,2110.7.
(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: = ` / - ' ' Applicant % 2 '
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 370113
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 employee's.
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) ! /'Y `''r - Date > }
BUILDING PERMIT PERMIT J!
DATE VALUATION LOT TRACT
JOB SITE ADDRESS �., 4 S�..i�i � IMI b«�N DE�d�%S�
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
IMCI. W..z l R 11 z 3dS ; .
DAVH)1 1 A►:9DDR31.1061
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USE OF PERMIT
1498 $.a'. SP PSP ?AA'D0F.,Sf NOTIINCLTH)F.r.BLOCK '&3AA1 PI;ACPUS:PA .
1 ,
A ldACT C(*44,14`1'RUCTiOw fe 9ir, J® r
r�191tCrlisl "%® 50.00 Zip
' CSAi`bAAFKARPORT . , . 467,90 U
FENTMM�`,f�) CoSir OF CON
Gt`�A1�T1�UO lU4 nx, 10 V -000.41 Z' -O pt) , 2603,30
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'1 ua,,;. 0i= 7M fix �0 X135-3'13 25f9s..a
Yd1: CSi htlCi D.1YLt5 101<000t gl21-.00,45. $i9xv
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F.M?z:C'j IUCAL 1.41IS 101.,-E p-420-o/o0 $110:27
:�1.�<JM;�ilYdttP�',� . t; �l-Cif)fJ•4�i I'A-Gtw S3 , . 51 !; ,.13113+
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,ft's X314-T'CYTI S.L G�r.�Y"ib'7.27 UC'TIt;3N Al PY AN. ti i
'nt PERMITJY• 81,30 R
t.ST,AJ :SRUJ .L7O•A4
V �� -
'tA tLk•X
JUL 0 2.2003'.
F,
CITY OFW QUINTe4 .:
IA1n ccag...
RECEIPT-�„"D'ATEM
BY i'
IPECT
DAT ' INrED O `
INS11
a
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
Set Backs
Bond Beam
Forms & Footings
Approval to Cover
Slab Grade
Equipment Location
Steel
Underground Electric
Roof Deck
/ jf
O.K. to Wrap
_
Framing
Gas Piping
Insulation
r—
Fireplace P.L.
Waste Lines
Fireplace T.O.
Heater Final
Party Wail Insulation
Party Wall Firewall
Plumbing Top Out
Exterior Lath
Drywall - Int. Lath
-
BLOCKWALL APPROVALS
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Final
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
- / — Q
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
COMMENTS:
mnai _j U'_ C/ bC�
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
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 1,498 S.F. or $3,205.72 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. 287294
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by $} r MCGilvrey
2MEMMWI l///��11fA4W
$3,205.72
Payment Recd
50.00
Over/Under
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 DistrictCs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
JAN -29-2004 05:37 PM
HERS.Rater
71 . �(-7
r
Plan Number
e Sample Group Number
P-01
�ifying Signature to Sample House Number
i`irm; C. d-�SSDGI e�sS HERS Provider: J. -4-X
Street Address: 7Ed40d�_'a6l F Yl CYL Lr_,2 cirylstatealp: ZN Q4101 -Aa"
Copies to: Builder, HERS Provider
HERS RATER COMB61ANCE STA ,I
The house was: Pr Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater provlding diagnostic testing and field vsrificatlon, i certify that the houses identified on this form
comply with the diagnostic tested compliance requirements as checked on this form.
VW Distribution system is fully ducted (i.e., does not use building cavitles 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 (Maxlrnum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow In CFM 7
If fan flow Is calculated as 400cfm/ton x number of tons enter
calculated value here
If fan now is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _. o
Check Box for Pass or Fail (Pass=6% or less) ❑
Pass Fall
IZTHERMOSTATIC EXPANSION VALVE (T)m or Commission approved equivalent
VYes ❑ 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
I 17 Yes d No ACCA Manual D Design requirements have been met
(rater has verified that actual Installation 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
t.°
Pass Fail
❑ ❑
Pass Fail
Certificate of Occupancy
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: 53-420 AVENIDA MENDOZA
Use classification: SFD
Occupancy Group: R3.
Owner of Building: THOMAS BUFFIN
Building Offi (al
Building Permit No.: 0306-412
Type of Construction: VN Land Use Zone: RC
Address: P.O. BOX 134
POST IN A CONSPICUOUS PLACE
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 1-30-04