0207-155 (SFD)LICENSED CONTRACTOR DECLARATION
(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
736,920 (13/3 112
Date �+ �� °'' Signature of Contractor
G
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 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 STATE FUND Policy No. 1971MA1y- 002
(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' compensatio�rovisions of Section 3700 of the Labor
Code, I shall forthwith comply withEth e'provisions.
Date: f 2 e1 l Applicant
Warning: Failure to secure Workers''Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on '•his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant, to
any permit issued as a result of this applicaton agrees to, & shall, indemni
& hold harmless the City of La Quinta, its officers, agents and employees
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellation
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the,:building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. N Y
Si nature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
0.30',-11°55
DATE tir�i` f �. VALUATION LOT TRACT
JOB SITE
ADDRESS s =�
APN
+ �.
OWNER
CONTRACTOR / DESIGNER EN 1NE,FE�R
y��vggy 7py� 9 p{
.�`iiJA.•$JLt`7f1i.0 r!A.lWii
�w
0100UJL1S�G3�.3F4L'►iw+l HOW a
- 11.0. BOX 1141
Y) 370 z?L�i'3�33?���A F�.�Ttsdt�7i7a
Lk Qumm& C& 9225J
Uk OUIN7AA CA P121253
62,55
USE OF PERMIT
EMU, FAMILY DMIMI-MG
001 S..F VD, .�'i�'l4F�i T ,C�0ISS'NOT INCI,X01? BI.,OCK'VI AL13d"POOL €�R
Mf WAY A.PPRG�AC I
f.
r
�'13.ACT CONN�';�UCTIOA1 1,501.00 �;a
..
G&RAMICARPORT 40.00 SP
:�N TED COSH' € F l:O:I�lu�'iTUC17'C11Tf
COAi�TRii�. TION FEE 101-000-419-000 W9.00
PLA34 C;i�ECK r�6Z 101-000-x•39-318. 4496.�S'"i
P» �1�f.1'I.l�Rd1C.�,i, awe 10,000421-000 '95%.50
RJAZTr�k1�°A1,FEE 101-00,0 P,20-000 1la:;a
i'i,CI Sk ll•Jfl;�'li : 101-0t.0-419-ork . 911Qi,7
S�'!t't3HO �If:�'1'10N M.;. ID 101-•'CfDi -241-000 $9.06
O.iZ,��:CiD40 ! +0.1-000rtd23.000 9151{10
.I.3I91 3PER>IAP AC3'FEE $AM,00
FRECIVE PLAN 101-000-441-345 00.441.343 5100100
Isb'•F:Ta�3r'QS'1�a 9f1iw>�0$P-��3'��3�6 a$15G.fifa
.�a,.��
l�y ♦ }4+�>� w Y 1 � �y �k�•p JC 4,g a T1T A T ,�T 7
G f�^�.4.6ll Hds`�.."+UbTa.°l • W(+�i J.'JLFY .G�.#'4d� d`.t..l^��i Z..�I.L��L�
¢� .!
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�OF.1"'�Fi7.eLiJ
Ai ir, 1 2002
CIYY OF LAQUINTA 1
FlNANCEDEPT. 1
RECEIPT
DATE
BY
D FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
U erground Ducts
Forms & Footings
_
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
Q ,
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
/
Compressor
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
�Q -�_ (�
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Laterar
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
— p_
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole O%•�� OZ���
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final / G;
Utility Notice (Perm)
COMMENTS:
�.,c ,,g.9"d6,,,q'y. ,.ry1-c`I'! ,'.,"'kR'.`�°'^*:n.;--wm-��...,cY.�""!r^cr-�+�,.-t-•�'3�isV.ulns'961d9�+*r $r
u��ttcv
P.O. BOX 1504 APPLICATION ONLY
Building S/ c^ r 78-495 CALLE TAMPICO
Address LA QUINTA, CALIFORNIA 92253
Mailing �l"w` , r7"
Address ,00 a //l/ ( . (/v7 7c. rr-L
City �q ) Zip Tel.
CR- q J� �
Address
Zip I Tel..
State Ljc. 1 City
& Classif. Lj "/ o ic. q
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 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.
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 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 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
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.)
1'1 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.)
17 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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
. F] 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 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.
I
CONSTRUCTION LENDING AGENCY
1 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 1 have read this application and state that the above information is correct.
Iagree to comply with 'all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant Date '
Mailing Address
City, State, Zip
BUILDING: TYPE'CONSTT. /� OCC. GRP.
A.P. Number -73 �f� j G 2
Legal Description /
Project Description
Sq. Ft. /
Size
New ❑ -\, "Ay(
'vl
No. d No. Dw.
Stories ' Units
❑ Alter ❑ Repair ❑ Demolition ❑
itimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. 5
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing i 4
S.M.I.
Grading AVA
Driveway Enc. R till
Infrastructure
luwx
CI~ E
TOTAL
REMARKS
e
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
Date 8/13/02
No. 23477
Owner
Buffin/Kellog
Address
P.O. Box 1141
City
La Quinta Zip 92253
Tract #
. 0207-155
Type
Single Family Residence
Lot #
Unit 1
Unit 2
Unit 3
Unit 4
Unit 5
Comments
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
No. Street
51955 Avenida Rubio
S.F.
1501
Unit 6
Unit 7
Unit 8
Unit 9
Unit 10
��tFu�sc
z4�eS�1TlfU.�yo.
Q BERMUDA DUNES r
RANCHO MIRAGE
. INDIAN WELLS
PALM DESERTLA
�3INDIONT p&_
D JY+L.��
i
APN #
773-161-022
Jurisdiction
La Quinta
Permit #
. 0207-155
Study Area
No. of Units
1
Lot # No. Street
S.F.
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 1,501 S.F. or $3,212.14 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 -Union Bank of California -Mark Kellogg Check No. 7924495
Name on the check Telephone 760-832-4641
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia $6,770.96 $3558.82
Payment Recd OverfUnder
• 4
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
l
,
5677
01/08✓01 10:25 FAX 17808049062 COMMONWEALTH TITLE (aj003
RECOROING REQUESTED BY:
AND WHEN RECORDED MAILTHIS DEED AND,
UNLESS OTHERWISE SHOWN BHLOW,
MAIL TAX STATEM=NTS T0:
�L-LlSV�10
ROBERT KELLOGG
SPACE ABOVE THIS LINE FOR RECORDER'S USE
The undarslgeted grantor(e) declare(s): Grant Deed A.P,N, 773-161-022
00cumnmary transfer tax is $
( xW computed on NII value of property conveyed, or
( ) computed on full vales leas value of fling and enournbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of anC
FOR A VALUABLE CONSIDERATION, rec®lot of which IS herepy acknowlelped,
JOHN ZAFLEET
hereby GRANTS) to ROBERT KELLOGG
the feat propeny In the City of La Quint:a
State of Cellfomie, described as
, County of Rive: -aids
Lot 1 if Block 33 17nit r"o. Santa Caxtnalita at: Vale La
Quint&, as per may recorded in Book )?ages _� of Maps, records of
Riverai.de Courtty, California
I.
Daled June 24, 2002
Signature of Grantor
Slate of Californi*
County of
On q�Qq� before me,
personally known to me (of proved to me CM the basis of aolle(eotory
evidence) to Ov the peraen(e) whose neme(e) le/ere subscribed to the
within ir+atrumara and eckhewfedged to me that helrholthey eKecrtec _
the Same In hla/her/their authonzaq capacily(fea), and that by — "—
hlsrhe,/their signature(s) on ft Instrument the peson(s), or the entity
upon behelf of which the person(s) acted, ex!cutsd the Instrument.
WIT.NE89 my hand and official seal
Signature
MAIL TAX STATEMENTS TO,
'd' M1 '011 wH07 : n I inn7 'fi?'err
,J c
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 per Section 9.50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house design does not duplicate the same architectural style of any
house within 200 feet of the applicant, and/or 2) if there is a need for the applicant to file for
Master Design Guidelines. If the -applicant does need to file a Master Design Guideline, please
transmitted this' information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT Buffer / Kellogg
SITE ADDRESS
APN 773 -161 - 022 CASE NO.: 2002-684
LEGAL: LOT
CHECK AND APPROVED BY:
BLOCK UNIT S.C:@V..L:Q.
Greg Trousdell
DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N
COMMENT/CORRECTION
Verify legal and APN information
Consistent with MDG on file (as
applicable
MDG filing required (5 filings since
9/3/98)
#
e
Architectural variety within 200 feet of
the surrounding area:
0-0
9
d
m1s
o� �2
ed
4 pian G
M
a1se.
Architectural design feaua%
tvol
r P LA 0I.{{NiA
6s JUL 0 0
Other Requirements:
BUILDINC-, raF�d;
FEB -05-2003110:04 PM
CERTIFICATE O
Project Title
hl -e XiVi-A L 4�Q
Ct AddJe6S
Builder NarYfe
Plan Number
Sample Group Number
Sample House Number
Firm:..J.0-. HERS Provider: TG vL 3n5oG/oZ�S
Street Adaress: 7���0 �r ick o✓� . t� vGt'� Clty/State/Zip: ZN 2taa g
Copies to; Builder, HERS Provider
ERS RATER COMPLIANCE STATEMENT
The house was; Tested ❑ Approved as part of semple.testing, but was not tested
As the HERS rater providing diagnostic testing and field verlflcatlon, I certify that the houses identified on this form
com.�ly with the diagnostic tested compliance requirements as checked on this form.
Distribution system Is fully'ducted (i.e., does not use bulldind 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
P. 03
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
d
--*-,-Duct Pressurization Test Results (CFM @ 25 Pa) Measured
Test Leakage Flow in CFM
If fan flow is calculated as 400cfm/ton x number of tons enter
calculated value here /6
If fan flow Is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) =, p
Check Box for Pass or Fail (Pass -6% or less)
❑
Pass Fail
2iTHERMOSTATIC EXPANSION VALVE TXV) or Commission approved equivalent
zyes
❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) Is Installed and Access is provided for Inspection
Cj
Yes Is a pass .
❑
Pass, Fail
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1, O Yes M No ACCA Manual D Design requirements have been met
(rater has verified that actual installation matches values in
CF -1 R and design on plan"
1"
2. ❑ Yes ❑ No T XV 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
❑ ❑.
Pass Fail
Certificate 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: SINGLE FAMILY DWELLING
51-955 AVENIDA RUBIO
Bldg. Permit No.: 0207-155
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: CONTEMPORARY HOMES
Building Official
Address: 51-370 AVENIDA BERMUDAS
City: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: MARCH 26. 2003
POST IN A CONSPICUOUS PLACE