0103-062 (SFD)LICENSED CONTRACTOR DECLARATION
I here Aafflrlm%nder penalty of perjury that I am licensed under provisions of
t Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force acid effect.
4License # Lic. Class Exp. Date .
7816-14
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&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 woik 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.
(This section need not be completed if the permit valuation is for $100.00 or less).
( )J 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 prgvisions)of Section 3700 of the Labor
Code, I shall forthwith comply with those provisioons.
Date: ' P-� Applicant"""^""
Warnini. Failure to secure W%kers�Cornpe cation verage is unlawful and
shall subject an employer to criminal penalties and vi' fines up to $100,000, in
addition to the cost of compensation, damages provided for in Section 3706
of the. Labor Code, interest and attorney's f
IMPORTANT Application is hereby,m de to the Director of Building and Safety
for a permit subject to the conditions and restrictions set 4orth 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 �„E
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its, officers, agents and em � ��:
2. Any permit issued as a result of this application becomes null aro � % �+
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 tot -enter upon
the above-mentioned property for inspection purposes. ,
•,,°-.. , .,,. 'gyp """"
Signature (Owner/Agent) ��"M% y1 �j Date 1 "P 4
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
i,a � � 'k%�ri4' '�..i:�
��" `L •p..,,.,...".. 'f �?f.���i� :2 ti.�4
JOB SITE
APN
ADDRESS
51 -'lea t�,''�E1esIDA R1;T..10
:.
OWNER
CONTRACTOR DESIGNER EN IINNEER
iMIiAua MOMAS
tR VMKM9.MI
C.A.
LA QLTJ.WDP.• Old, 922:53
(760)409-5422 Cwh 2301
,
USE OFPERMIT
MVIrkAY FYYO -
ID .1 T t��f7�ES N1�nJ�'fr�� INCLUDE .i3b:�3CK `d�+A, US, l�a�t�sF:� Ofd E�RJ't n i.Ay
�khh:�pp:Yl!21cc
APPPLAN RA -1
TICT CDNFY'II,'Ud TI(Yt• 1,,fiiil�eS SE
POP,CIMPAX10 %00 5?
0ARAGWAR['`IDRT (SF) 01"4,30
3 7r, 'WOOD 3' ENClr, 300.03 LP
1=;I1=tJti' (tip �:'EdRid.'°1t°E
,
00NO`I'ki'tiCTION PER 101-000-418--000
R,xAN CHECKFFA? 101-000-449-318
M)'CBANIC.],• I?VE 101-000-421-000 $0.00
BLICIVIrAL,rim4 1--�6�!0•ifi l:3l. t�
I',ladll DIHO.Mr, 1C'1Site,".
S"iIL!-9NO.MOTION, _ WO -'241-000 $9.:31
ti;1.I1&.D1wo WE $20.00
Me`d•I:POP71:rR IMPACT ME �Y,9f9^.L Do
PRE ME pwi 101-000-44.1-34,1 $100.00
101 -OW -4n)-318 4250.00
11 12 2001 sO A•-`.isMAL COMM1.T1:`. 101'T AVD AM ��E..,i'`;IC
`$31ry464.�3(1�
y rpt � �
"'NNS PFE-1'. �' rO �i4WZW
`Q LJfr 'L�. ViR
x
RECEIPT
DATE
JJ
BYE *
r ,
DATE FINALED
INSPECTOR
4t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
��
Ducts
Slab Grade
_ _
�ji�
Return Air
Steel
Combustion Air
Roof DeckExhaust
_
Fans
O.K. to Wrap
F.A.U.
Framing
�(��a (
✓/
Compressor
Insulation
=�T p t
>77
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'Drywall - Int. Lath
Z
Final
Final
� — L'3 _ o /
S"7
'
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
-
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
_
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
(
G /J
Heater Final
Water Piping
I
J
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
• �_ , 6�
3
7
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
— c?
Utility Notice (Perm)
'-1
Building / �$S_A 2 VJI D
Address J
Owner
-T�towco J'A",
Mailing
Address Po 9 -OK 13 Lf
City I Zip Tel
C3 oA .5 17
Jll^TA z1pgZ.7_.S3 Tel.
�1S
State Lic. I City
& Classif. ' Lic. #
Arch., Engr.,
Designer
Address Tel.
City (Zip (State
Lic. #
P.O. BOX 1504 APPLICAT O ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
70001
of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE 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 rile 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 f$500).
I: 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, Buisness and
Professions Code: The Contractor's License Law 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
or improvement 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.)
II 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 (hereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
0 1 am exempt under Sec. B. & 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
n Copy is filed with the city. ❑ 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, after making this Certificate or 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
Ihereby 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 if 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 a0plicanl Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 17-73 /6/ 0/3 /
Legal Description /_ O T -Z-a 1 %'= ,:�> J POT �-
Project Description
SA.A r9 CAKulF(, fT.a a1- VAL-C i-A4v1It1r,4
Sq. FN
Size J, I 0 I 4.
New E2/ Add ❑
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
No.
No. Dw.
Units
Alter ❑ Repair ❑ Demolition ❑
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
OUNT
Notice:
Document Cannot Be Duplicated
Date 3/12/01
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
No. 21753
Owner NameWilliam Thomas Buffin
No. 51=785 Street Avenida Rubio
City La Quinta
APN #
Jurisdiction La Quinta
Zip 92253
773-161-013
Permit #
Log #
Study Area
Tract # BLK33 U2 Lot # 2 Square Footage 1501
Type of Development Single Family Residence No. of Units 1
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 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
2.05 X. 1,501 or $ 3,077.05 the property listed above and that -building
permits and/or Certificates of Occupancy for this square footage in this proposed project maync Abe issued
Fees Paid By CCNalley Independent Bank - Mike Brauckmann Temp one 760-4 9-5422
Name on the check`'�>� C'g
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow
Vv w l
Signature
`Payment Received $3,077.05
Check No. 235352
40TICE: Pursuant of 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
yt
9/01 10:25 FAX 17608049062
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TO;
William Thomas .Buffin
Power Brokers
P- O- Box 134
La Quinta, CA 92253
7075
SPACE ABOVE THIS LINE FOR RECORDER'S USE
�6
The undersigned grantor(s) declare(s)- Grant.Deed A.P.N. 773 01 3-9
.Documentary transfer tax is $
computed on full value of property conveyed, or
( �) computed on full value less value of liens and encumbrances remaining at time of sale.
( ) Unincorporated area; ( ) City of and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
William R. Riley, Trustee
hereby GRANT(S) to WILLIAM THOMAS BOFFIN, an unmarried man
the real property in the City of La Quinta Coi/nty of Riverside
State of California, described as
Lot 2 of Block 33 Unit No. 2 ' �
r Santa Carmelita at Vale La
Quinta, as per map recorded in Book 18 Pages 55,56 mf Maps, Records of Riverside
County, California
Dated 2/1/01 Signature of Grantor
Stale of California )
County of ) SS.
On before me, William.R. Riley, 4rustee
,personally appeared
personally known to me (or proved to me on the basis of satisfactory
evidence) to be the person(s) whose name(s).is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed
the some in his/her/their authorized capacity(ies), and that by-✓•
his/her/their signature(s) on the Instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature
MAIL TAX STATEMENTS TO,
FOrfil 31961 (6-94) THIS FORM FURNISHED BY COMMONWIALTH LAND TITLE COMPANY
I
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove Residential)
District, in order to determine the applicability of compatibility issues or need to require the filing of Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as your
correction list. Please attach additional explanations as necessary.
APPLICANT Brauckmann Inc.
SITE ADDRESS 51-785 Avenida Rubio
APN 773 _ 161 _ 013 'BIN NO.: CASE NO.: 2001-413
LEGAL: LOT 2 BLOCK 33 UNIT 2 S.C.@V.L.Q.
CHECKED BY: Wally Nesbit DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD -Executive
Secretary maintains a log book togack applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Compatibility Review
i/
iV /,4
Case logged and number assigned
Verify legal and APN information
7"7r" ,s v: ✓S �s+'�+�
Consistent with MDG on file (as.applicable
MDG filing required (5 filings since 9/3/98)
N/A /VOA ( AV2R 9 vG6Cw,t ni/L
Consistency with street/surrounding area:
Colors
Materials
Architecture
At.& G►' a` 10-`` `' °`a4.,M "&?0A4f-S
tJ
Other Requirements:
)Rroyed hrv"«°
Planning Commission _
City Council ..._.-._...
commun Dev. Dept
o ---,S
y v� s�iry
�(�. w(.,;)As T, aE s/1"/G4?2 70 r�44.
G OI- '//4
Case No. ,�..__.,..,�-.----
Exhibit - - ...,_..... , _
'With Conditions ...........,..
OV
F-
'\\
Certificatel'of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SFD
Occupancy Group: R 3
51-785 AVENIDA RUBIO
Type of Construction: VN
Owner of Building: WILLIAM THOMAS BUFFIN
Building Official
Bldg. Permit No.: 0103-062
Land Use Zone: RC
Address:
P.O. BOX 134
City:
LA QUINTA, CA 92253
By:
STEVE TRAXEL
Date:
08-13-01
POST IN A CONSPICUOUS PLACE