SFD (0308-230)LICENSED CONTRACTOR DECLARATION
1 hereby-Zffiim 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
f�i3."w�'ti7 � .. 17111I2�
✓ate j Z Signature of Contractor44w
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 maintairi 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.
(�)r 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 STATE FUND Policy No. 229- 001""-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 pro isions.
Date: 1 "• Applicant
Warning: Fal1u a to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00,000, in
addition to the cost of compensation, damages as provided -for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information'is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize ,•rfpresentatives of this City to enter upon
the above-mentioned property fovinsspection purposes.
/.�/':'7Jrt
Signature (Owner/Agent) �.� �.{ � Date
w , �,--�,_ (,;) yr • ...•
_BUILDING PERMIT PERMITk
_
-2
DATE VALUATION LOT TRACT
BIX242,
JOB SITE9ry��•`"" ^ -
ADDRESS a '� i d � FJ A dr 9 .1 �O94it
APN
i 74-133$ IW
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P.O. BOX 134
*,4 1 / 80 :ffX�'AGE DR. '
LA QZ7iA rA. Ck 92253
BIMMUDA DU14 S C.A, 92,201
-1t
(760)408-7528 M# 3724
USE OF PERMIT
f'� i
����p,yy//••}}yy qq,, y� p�•py.+ipr•rye^y��sp.i.�.•'�•��,y�ry
Vi57 VJ..a9.'.. b'�AV:.LA.• 1 /..+ W;W �t.aLAV LT' i 1
.
i498 S.I? -SF ... FTM1IT DOF..S 140T INCd,•U69 BLOCK WALL, P001A:3PA
OR D.RIV'IWAY APPROACH i
TRACT COpda3`PI AUCTION J,498.00 SF
PORCIVPATlO . 50.00 SF
CIARAC9UCA RPOR T 467.00 SIS
' EQTh.Li' XMID C09 OF `6r4:/57aS .1'.d�.i9 w..710
r 9�.s7TJut+
CONSTRUCTION ION FF% 101.000-418-000 UO3.50
PLAIN CHECK FEZ 101-000.4`59-318 $503.32
'
FEE DF.POSIT 101-000-439-318 ,0250.00
MECHANICAL FRE. $59.00
ELECTRICAL FSE F . 1 U1�c,+JCl 2t1�OQ70 5110.
PI.LJ718BINQ FRE 101-0.00-419-000
a1'I'R(YU0 MOTION FEE - REBID . 10 1 -000-Z 41 -000 M12
�RI�IiPNt3 101-00.0223-000
1)i'�V 91LO SER IMPACT FEF $2,403.00
RRW1139PLOT E(id-OE?d7-4811-3q� $l0fl.aiJ
.
SUB -TOTAL CC?At:WZUf>`TI.O24 AND I`E,.AN CITICK
$3,923,21.
- US* PRE, —PAI FM
' 4250.00
s
AUG z 200
(QITY OF LA ®UINTA
+FINANCEZEPT a _
RECEIPT
DATE
BY
I ED'
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- O
F.A.U.
Framing
2 O
Compressor
Insulation
-Z
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
0 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
v
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power: -
Final
Utility Notice (Perm) �/
COMMENTS:
eq -3 08 —2-3 0
Building `rG�O
Address
Owner
Mailing
Address
•4 4 "
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
VAv�.t� LA QUINTA, CALIFORNIA 92253
�;G4a4,
Address /-//- / V61 -CZA7' !991I.- Ae I
®d-75�F
State Lic.� I City
& Classif. /'iP� d1� / Lic. #
Arcn., tngr.,
Designer
Address I Tel.
CityI Zip I State I
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.
�GNATURE 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 to construct, 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 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).
I.: 1, 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 Caw does not apply to an owner of property who
builds or 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
orimprovement 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.)
I'I 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 contractor(s) licensed pursuant to the Contractor's License Law.)
I'! I am exempt under Sec. B. 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
fl Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above-
mentioned property for inspection purposes.
Signature of adplicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST.OCC. GRP.
A.P. Number1,�
Legal Description '6_7 : (&4 4'Z
Project Description
Sq. Ft.p No. No. Dw.
Size fl yp Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
i
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. Z$ b �—
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear P o .Line
j -greet Sepack fro j� ter Line
SideLSefbaCkAlNm-1 ro t . ine
FINAL DATE EC
ti IUB 2LO
Issued by: =+ y Dtrmit
Validated by: fnO'iaUJNTA
Validation:
l
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Date 8/21/03 La Quinta, CA 92253
No. 24853 (760) 771-8515
Owner
Thomas Buffin
APN #
Address
P O Box 134
Jurisdiction
City
La Quinta Zip 92253
Permit #
Tract #
BLK 242
Study Area
Type
Single Family Residence
No. of Units
Lot #
Unit 1 17
Unit 2
Unit 3
Unit 4
Unit 5
Comments
No. Street
5360 Avenida Mendoza
53fo�od
S.F.
1498 Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
qN��F1Fns,CO
� o
< BERMUDA DUNES r
00 RANCHO MIRAGE
INDIAN WELLS
PALM DESERT y
LA QUINTA
"QINDIO y7i
q
774-133-008
La Quinta
0308-230
1
Lot # No. Street S.F.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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. 287397
Name on the.check Telephone 760/408.7528
Funding Residential'
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon MCGilvrey Payment Recd
$3,205.72 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 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
MAR -30-2004 05:23 PM
P.01
CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC TESTING CF -411
Firm:.) _G,, d' SSOGl�( e
Street Address: ��'` ✓ !
Copes to: Budder. HERS Provider
guilder flame
Plan Number
Sample Group Number
Sample House Number
HLKb rrovider: T-G��, i syocia7-A
CltylStats0p: L w Gnu /n rC g 9; 2,;� 3
HERS RATER COM L T TEMENT
The house was: do Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verificatlon, I certify that the houses identified on this form
co�ly with the diagnostic, asted compliance requirements as chocked on this form.
Distribution system Is fully ducted (i.e., does not use building cavities as plenums or platform returns inlieu
of ducts)
Where cloth backed, rubber adhesive duct tape is installed, mastic and drewbands 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 Q 25 Pa) values
I Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated here
value
If fan flow Is measured enter measured value here
�f
I eakaga Percentage (100 x Test Leakage/Fan Flow) 7 7 d
Check Box for Pass or Feil (Pass=6% or less)
❑
ass Fail
LffTHF-RMOSTATIC EXPANSION VALVE (TXV) or Commission upEroved equivalent
t
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
i . Q Yes Cl No RCCA Manual D Design requirements have been met
(rater has verified that actual installation matches values In
CF -11 R and design on plan,
2. Q Yes C3 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 =
C 0
Yes for both 1 and 2 is a Pass
Pass Fail
Cal) ccupancy
Certificate of 0
� Y
0
t4
V
71
OF Building & Safety Department
i
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 compHance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: -53-660 AVENIDA MENDOZA
A
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0308-230
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
By: KIRK KIRKLAND
Date: March 31, 2004
Building Official
1 T4
POST IN A CONSPICUOUS PLACE