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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
6134981 D i ;ID1/31 {
Dater • '� Signature of Contractor*-; •.;� -f � ••
OWNER -BUILDER DECLARATION
Thereby 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:
Carrier Policy No.
w`iA'�Z FUND 154 07-01.
(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 rshould become
subject to the workers' compensation provisions°of Section 3700 of the Labor
Code, I shall forthwith comply with.those provisions.
Date: 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
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 ' r;
& 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 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 forinspection purpose's.
i f / :..
Signature (Owner/Agent) / - f Date' • -1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 023 -1$1 TRACT
$113,244.70 9 MK '779
f , -1
JOB SITE
ADDRESS 54.,MA:VENIDA.i'C"IU;N
APN
774-29"21
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TWYMMS BUFFM
f;1ORONFIL C° 0)9SnW'a110N
PO DO3a 1.54
78=150
X.,A.Q11d1`t'1A CIA. 92253
sf"QUIN'TA CA 92253
C760)564.4604 10BL ~ 2261
1)9
USE OF PERMIT
f1,WGLBFAN!V,Y DWELLING
SYS?? • P&RMIT VOUS 140T'INC:1 UD -9 Ut Ol.K VVALL, POOL, OR ORWWAY
APPROACH. 99 COW
TRACT CONSTRUCTION 00.71V SP
PORCWRATIO 38.00 3F
<,1ARA.0r4CAF00RT 491.815 Or
01P CONKrICTION
113,244.70COST
1E.WCITESj1MAR
CONSTRUCTION CTION FEE 101-000-415-000 5-000 SOg,>
D
LAR�f�gL+,HECg�t3e�. FEE 1033-00a439-319 $569.16
Y}, /���y+
L'�aC'✓.W7b�P0S1 d 101-000-4,39- 18 ��.�fiJt�X
p1
-MECH 1:,AL MY 1 GS _000.421-000 WAND
ELECTRICAL FEE 101-000-420-000 9121 M
P1lum-81HO . TIE : 01 -.0-00-419-000 $1160
s
:1'1'1 ONO MOTION YS 9 - kESID 101-000,141-000 si 1,
2
ORAL YNO 7LL 101-000..423-0810 $2v
A- .
DE fIl(.,O.PER. HAPACT FEE 61.907SO
OLtiClSRlSLAEd 101.-000441-�45 a14f1.tt0
. SIM "T0.1.C1t,+'4.'�.OR`��.7.t l.`1 t.r t.i�.OL� 2�1 2.g L�.t�+T1.1V a.i6A t.�.:Lh,
$?,59O. Y&
U,0 RPX-PAID PER -4
��250.00
D T91.&L 2009.r NVk S DIM NOW
CITY OFLAQUIN-M
F
RECEIPT
DATE
BY
DAT FINALED
INSPECTOR
...z — F-- ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
S
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_p
Compressor
Insulation
_
Z OF
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
5p -Vj
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
_
Heater Final
Water Piping
71
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection/O
Z__.,
Encapsulation
Gas Piping
GGG
Gas Test
Appliances
Final
Final
Utility Notice (Gas) l%Ta�—
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 G
Final _-
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 4/8/02
No. 23113
CERTIFICATE OF COMPLIANCE
APN # 774-294-021
Jurisdiction La Quinta
Owner NameThomas Buffin Permit #0203-181
No. 54925 Street Avenida Carranza Log #
City La Quinta
Tract # BLK279
Zip 92253 Study Area
Lot # 9 Square Footage 1899
Type of Development Single Family Residence No. of Units 1
Comments
Construction of new single family dwelling
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 or replacement mobilehomes. It
has been determined 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 Government Code 53080 in the amount of
2.14 X 1,899 or $ 4,063.86 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 VIP - Ish Coronel
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Crystal Scott
Signature
Telephone
Payment Received - $4,063.86
Check No. 264612
JOTICE: Pursuant to Assembly Bill 3081 (CHAP 549, STATS. 1996) 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 sssued or on which they are paid to the District(s) or to another public entity authorized to
:ollect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
JGr - 1 J. -Gt017L b 1 S5 "M
C* ..R'F1FICATE OF FIFiD VERIFICATION AND DIAGNOSTIC TESTING
Project Title
P,oiul Address
6uito.g_ Cont celephone
11w �2Y=�57 23
HERS Rater T lephone
,' e yang Signature� ore te
Firm._sr/tu_ZW 11L" -- e(` Q
Street Address. %�ibZU 9;,41 v�C r, ) "-
Copes to* Builaer. HERS Provider
ay
Date' '
Builder Name
Plan Number
Sample Group Number
Sample House Number
HERS Provider:
Clty/State/Zip:
P-03
CF -4R
HERS RATER COMPLIANCE STATEMENT
Tne house was: ❑ Tested E] Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form
comply with the diagnostic tested 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 leeks 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 C�
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated value here
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 !ass)
❑
Pass Fail
t THERMOSTATIC EXPANSION VALVE (TXV) or Commission approvcd equivalent
Yes ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is Installed and Access is provided for inspection❑
?ass --
Yes is a pass
Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
O Yes ❑ No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1 ft 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 -1R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
Pass Fail