0111-057 (SFD)LICENSED CONTRACTOR DECLARATION i
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 Busiriess and"
,,R_rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
.i
B1 C9
e !•f Signature of Contractor !i
OWNER -BUILDER
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 employs 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). 11
( ) 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 ,,T.KrF; Ft)kyif>Policy No. SUP -Oa UNIT 1/011090
(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 rovi�sions of Sec(ion 3700 of the Labor
Code, I shall forthwith comply with th se provisions.
Date: �, i� _ , Applicant tt. ft!. !',o�ti�
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.
11;, 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. Ariy 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 reyesentatives of this City to enter upon
the above-mentioned property for iWspecb on purposes., _>}
Signature (Owner/Agent)' tA Date
BUILDINGPERMIT PERMIT#
DATE /M.. / VALN ti _OATIO_ '! i ` _ ' LOT . ` L � � TRACT
JOB SITE
APN
ADDRESS 53 } R.(tB10
774
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�®..
p "
'•���a7�rTyr�
���•p rp p� [ Y�•�aLy'�7
W.4&.et..�1t" NI O:S LAFEU ., `
N: {���,p s�!
T•���
PAP 1,�yioY`Oe�A.i,R0.J4�LQ4J1�Yco ..
5 2-995 AV E NWA1VD'KND07,f'., d
1A QUWTA, Ct, oin
LA Q{PIN'rA CA 92253
$537
,,G.mn
USE OF PERMIT /
�:.
P00USKA OR DUVEWA it .A,.P)EsFYG?.!!.{..Fji • ',., �'�
1
TRACT 4:015 T R C i'1ON 1,465, 00• S
PCIRC IPAT C 243.00 SP'
,RAOTYC1 RFORT 458.00 SF
s 5n" WOOD i )Gz 20.00 LF
CON0T11 CTION .FEV' 1014=41P-000 $609.001
PIAN C119rK »7'9 101-000-439..318 %-51 .39
101-00 0-421-000 $60' 0
RUX T ltlr A -L YFF 101-000-420-0010 $i r.94
PI.Uk11BINO FEE 101-000-1 -000-419-000 1116171
STTkO'NO MOTION FEE • F'A S1X) 101 -0004A 1-000 $S►.2S
G-RADING FFE, 101-5100.42:3-000 S2�T.dt!t
0i4'b'L1..G).PF,R IMPACT YFZ $1,907.00
PRECISE &SLAW 101.000441-345 $100.00
"Of, 132POSIT 101-000-439-318 4250,00
HUB -TOTAL CIO 3d, YRITC"3101\1,IAN:ti1;)a3: AM MIE
�13,4E�2. 31
TOTAL PERMIT Zq_11i_18 DITE NOW
RECEIPT
DAT
BY BY
D FINALED
INSP 0
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
�_ d �-
Underground Ducts
Ducts
Slab Grade_
Return Air
Steel
_�
Combustion Air
Roof Deck
O.K. to Wrap
Exhaust Fans
F.A.U.
Framing
,- %.
. Compressor
InsulationZ �� Q2.
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
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
Water Piping
i
-�
Heater Final
Plumbing Final
Plumbing Top Oul
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�� CG �✓Z�
_ `/%
Appliances
Final
COMMENTS:
Final _
Utility Notice (Gas4
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Con•iuit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacl=s
G.F.I.
Smoke Detectors
Temp. Use of Power
-
Final
Utility Notice (Pere) 6G9pi
11_11���� 1� ��Y•��i"Vi<7'v�C���� ; ebb'�.Jt����,��i��f���sr�s+rsy.-rtT'f,T.i"'"'�('t"`�®
4'0
t�l�cv
,� 6
P.O. BOX TION O L�/�
Building 53-z 78-495 CALLETAMTAMPICO APPLICAI
Address J 0,% 3 LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address u ,�
City Zip - Tel.
It, 0 X-,, L -L S
Contractor Co
AU CC t-C1✓1-i
Zip
State Lic.n
City
& Classif.
moi-
�rJ 5—� 5 -
Lic. #
Arch., Engr.,
Designer
Address
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.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.S.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 thealleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penally of not more than five hundred dollars ($500).
(: 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.)
I 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 contractors) licensed pursuant to the Contractor's License Law.)
11 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
r1 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars (E100) 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 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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of aOplicant Date
Mailing Address
City, State, Zip
.DING: TYPE'CONST. OCC. GRP.
Number -- -) o `2_ ( 1
,I Description G, -)-r
,ct Description VC n 7 —k-\ /`-5-- 4
Sq. Ft. No. No. Dw. !
Size 14 Stories ` Units 1
New V Add ❑ Alter ❑ Repair ❑ Demolition ❑
0
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
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
Notice:
Document Cannot Be Duplicated
Date 11/30/01 )
No. 22725
Owner NameWilliam Buffi'n
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # 774-043-012
Jurisdiction La Ouinta
Permit #0111-057
No..53-240 Street Avenida Rubio Log #
City La Quinta zip 92253 Study Area
Tract # BLK254 Lot # 13 . Square Footage 1465
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 1,465 or $ 3,003.25 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/VIB BANK -Petra Carrillo Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia Payment Received $3,003.25
Check No. 259714
Signature
NOTICE: 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
collect them on the Dist ict('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
01/12/01 14:00 FAX 17608049062
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TO:
William Thomas Buf.fin
Power Brokers
0.0. Box 134
La Ouinta, CA 92253
;i
......... .. ...................
COIWI NWEALTH TITLE 121 002
The undersigned grantor(s) declare(s): GI
Documentary transfer tax is $
( x computed on full value of property conveyed, or
( ") computed on full value less value of liens and encumbra
( ) Unincorporated area: (, . ) City of
FOR A VALUABLE CONSIDERATION, receipt of which is here
MIGUEL CARRILLO
v
hereby GRANT(S) to WILLIAM THOMAS -BUFFIN, an
the real property in the City of La Ouinta
State of Califomia, described as
Lot 13_& 14 of Block 176 Unit No.
Quinra, as per trap recorded in Book
County, California
Dated September 7, 2001
Slate of California )
County of ) SS.
On before me.
Personally appeared
--MI=EL CARRILL
personally known to me (or proved to me on the basis of salisfaclory
evidence) to be the parson(s) whose name(s) is/aro subscribed to the
within instrument and acknowledged to me that he/she/they executed
the same In Ills/her/thalr authorized capacity(les), and that by
his/her/their signalure(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,
SPACE ABOVF TI-IIC I IAIF no oennmmen
!ed A.P.N. 774-043-011.11/012
atning at time of sale.
and
ed,
ried man
County of Riverside
Santa Carmelita at Vale La
mf daps, Records of Riverside
Signature of Grantor
MIGUEL-CARRILLO'
-r
it } j ., r • ;
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 20-01eef 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 PAZ CONSTRUCTION
53-20
SITE ADDRESS Avenida Rubio
APN 774 - ' 202 -_011 CASE NO.: 2001-572
LEGAL: LOT 13 BLOCK • 254 UNIT S.C.@V.L.Q..
CHECK AND APPROVED BY: Michele Rambo 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
X
Consistent with MDG on file (as
applicable
NI
MDG filing required (5 filings since
9/3/98)VOT.
Q�
Architectural variety within 200 feet of
the surrounding area:
Colors
Materials
Architectural design features
T61—
JWM
SEGO•
Other Requirements:
r
1'jN'W'ALLAT1n\: rrD"r T Vr,-%
P. 05
DUCT LEAKAGE AND DESIGN DIAGNOSTICS
6CAMUE REDUCTION
PressurizOtion Test Re3ulte (CFM ®2S Pqj
Fan Flow Test Leakage (CFM)
tt 1 "Fan Plow is
"Calculated as,400,crmlton x n,.frnbe'. GrICnit, 0lag 2,,? x
,Heating capacity
in Thousands of Bru/hr, enter calculated Value here IrD
if fan flow is measured, enter measured value here
LeakageFtuc!ion ■ Test Leakage/(Measured or Calculated Pan flow) - Miff
Pus if leakqe'6actjon 9 0.06
'ALANTS ONLY - The following digg —
f?r4
�,ZROSOL TYPESE Pass Fid
nostic testing w2s completed:
J Duct Fin'Pressurization at rough -in measured leakaSe (CFM)
C
CREK AFTER FIN
If I$HfNG WALL. -
Q
ressure,pan test or House pressurization test
viiuil inspection of Duct cmections
A
Pass F4d
r—THEFtMOSTATIC, EipANSIOLI k,
tALVE(TXV)
No 'N:! . ctiteital ' ic P ' xPansion, Valve (or Commission approved
equivifent)"Is'installed and Access is provided for inspection
Yes is a past
DUCT, DESI . 0 - N Pigs Fail
0 �Yeq❑ No ACOA :Manual —D-;egian calculations=have-peen complete . .........
----
Duct Design is n" the Ploo$ and duct iratallation matches
plans,
2.
YtsQ No TkV ig installed or Fan now has been MO&L If no TXV,
verined t1sn
Measured ion Flow
Yes for both I and 2 is a pass
Pass Fail
the undersigned, verify t1hAt the above diagnostic
cunfmrnAnct with the requirements for compliance
test Mults And the Work*1 performed associated With the test(s) is in
yeo.q 6,, jL1b
credit, (TInc. builder shall provid
_co"lractors 6 s ; 0 the HERS provider a COPY Of the CF -6R
credit.- , I ert'fy'ng that d'89ntic .0. icst,n& Mid'installitiun meet inc reqL1ir."n-.j)t, fj.,,
4 2-
F
jjnAruret, Dare
VY a n i7- r J -r,
'c r "'or
I n�t d . ,
COPY 7C): Fjtij;d!ng
epammert, General, Contractor (Co. NAMC)
:TEAS Provider ('f.Whczble)
Owner at oecupg.
.Icy
M
t
A
Project Title �Y �D 64
ng
Firm:
Street Address:
Copies to: Builder, HERS Provider
AT]
G
Tele none Plan Number
ie ane Sample Growl; Number
to amp a owes Number .
HERS Provider;
F
NERJRATER CQMLfNCE STAT_IMENT
The house wag: WTested `❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, I cortlfy that the houses identified On this form
comply with the diogrnostio tested compiiehoe requirements as checked on this fora,
25-T)Wrlbution system is fully'ducted (i.e., does not use buliding cavities as planGm® or platform returns in lieu
of ducts)
1Gi where cloth bb4ftd, rubber adhesive duct tape is Inetellad, m®sto and drawbande are used in Milbinetiort
with cloth backed, rubber adhesive Auct tape to seat leaks at duct connections.
96"MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage.Tebtlnq Results (Maulrnurn 6% Duct Leakage)
Measured
Cuct Pressuri atlon Test Results (CFM aC 25 Pa) values
Test Leakage Flow In CFM -
If tan flow is calculated as 400cfmlton x number of tone tinter
calculated value her® 92
If fen now is measured enter measured value more
Leakage Pereentage.000 X Test Leakege/Fan Flow)
Check Box for Pass or Pail (Passr.6% or less) - ❑
Pees Fall
THERMOSTATIC EXPANSION VALVE (TXV) or, Comm' issi.on approved equivalent
&ryes ❑ Na Thermostatic Expansion Valve (or Commission approved
equivalent) Is Installed and Aceeba is provldea for inspection
Yas is e,pe>,a eas 'Fail
❑ `MINIMUM REQUIREMENT$ FOR DUCT DESIGN"COMPLIANCE CRWIT
t) Yes 0 No, RCCA Manual D Oe91'gn;requlydments have been met
(rater has verified that` etual Installation matches values in
CF -1;R and design, on plan, � ��� .
2. 10 Yes 0 No TXV is installed or Fen flow has been veriffed, if no ITXV,
verified fen flow matches design from CF -,1 R.
Measured Fan Flew a
' O O
{ Yes for both 1 and,2 is a Pass Pa6s Feil
'r
Certificate of Occupancy
City of La QuIN .
inta
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: 53-240 AVENIDA RUBIO
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction:
Owner of Building: WILLIAM BUFFIN
Building Official
Bldg. Permit No.: 0111-057
VN Land Use Zone: RC `
Address:
P.O. BOX 134
City:
LA QUINTA, CA 92253
By:
KIRK KIRKLAND
Date:
AUGUST 9, 2002
POST IN A CONSPICUOUS PLACE