0010-058 (SFD)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# y.p Lic. Class Exp. Date,{
��ir�1ti0 � '� � 5✓ �.a�Ji.�Q�'�ri'
Dat ( i. Signature of Contractor
V N
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:
Cartier Policy No.
(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 Califor ia, and agree that if I should become
subject"to the workers' compensation#roviisions of Section 3700 of the Labor
C506, I shall forthwith comply with th visions.
Bate: t /? Applicant -
Warning:
, -•
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 f?
whose request and for whose benefit work is performed under or pursuant to Y`?
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 autho ize representatives of this City to enter upon'
the above-mentioned property f r in 4 ection purposes.
a �
Sigmafure (Owner/Agent) Date �1' `b�1 #n
BUILDING PERMIT PERMT#
DATE VALUATION. LOT. TRACT
JOB SITE
APN
ADDRESS
;
&V575 AM11143ARC1 TO
► 74-11 "J 4 ..:.
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PO Bt» ) 3
5137 0 ANkMi 5A181 UDAS
TA QjMgfA CA 92253
LAQZ731+1`£A • C.A. 9225:
_
(76q$64-1462 Muk 6253
USE OF PERMIT
SPIM"I .' 9PIPIN11'1' DOES Nur rNC1..[J02 BLOCK 'tA3'ALI ZVr OLIAP1►ROAC.H
L1�1PL ISSUANCE OF
SAKE P'L kNl T'IrTP , f'EE EDucf io
AAM COW RUC:11ON 1,421.00 EP
is'O1:Ct'!(I:'Ji►.TIO 36.00 3-F
0MACEWA1?PORT (S) 91996100
5 FT. ''E OI.')D M C 9 200.60 YIP
MIMTED COST OF OC)!` STRUMON
11P,. 35.10
:t1 mulr:I iri SUMMARY
CONSTRUCTION PER 10.) -0'1{1-41 8 -ow, $194.50
PLAN i'110 FED: 101-000-439-319 $113.12
MECHANICAL MY, 101-000-42,1-000 00.4211.000 $6100
141A¢CTRIC'IAl„ 7Fi 3n2. -A2 r- �1�9:rt�1
TRIONO M0'c10*4%1 i7..1r - RES -40 101-000-241-000
G1YAY INQ FRE, 1.01.0100.423-0(M) MOO
DEVELOPER IMPAC7 ME $1,90181)
R.RWISE fji.M '101-000.441.346 $100.00
FEE MPOSIT 1,01-000-4,341-318 4150.00 .
i 1�TaS.S PPMXIAMM,, 117
42.+4},00
MIX., EMMM"FRU DUE NOW
PAID
r
OCT 0.9: 2000.
04T
RECEIPT
DATE
B!
D E NAL
INSPECTOR
;
J
i
iNKle"`7.
INSPECTION RECORD
_OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _ _ _
�j7
Underground Ducts
Forms& Footings
fes(
�l yl
Ducts
Slab Grade
`
Return Air
Steel
Combustion Air
Roof Deck
-2Q — < 7
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
3 -- `✓- 7
Compressor
Insulation
3 —p 5 2
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q
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
Waste Lines
_
t� /<2
Electric Final
Heater Final
Water Piping
` [
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection"
/l� 6 ( .�!
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
--8
Utility Notice (Perm)
Building S3,-
Address
Owner
4 4 "
P.O. BOX 1504
78-495 CALLE TAMPICO
�C, yU LA QUINTA, CALIFORNIA 92253
Mailing ^� ' 3H
Address � l.. ti �
City Zip„ Tel.
Contractor
Address? 1
City Zip . Tel
State Lic.1'.3 Q ��, City S
8 Classif. \Lic. # �� S
Arch., Engr.,
Designer L ( 0« L J(W-
Address Tel
K; 3
CityLZip,. State
t+ �i J l i Lir. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Iicerr eA1under provisions of Chapter 9 (commencing with Section
7000) 01 Division 3 0l the BUS' ss aPd Professions Code, and my license is in full force and
effect. •+ / ' 1 1 4. 11
i s o
SIGNATURE 9 ff`llll _f DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8
usiness 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) or
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." 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.)
I -I 1, 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.)
1-1 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
r7 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 work1or which this permit is issued, I shall not
employ any person in any manner so as to begofne bject to the Workers' Compensation
Laws,9fCalifornia.Datei
Qyyber i 1
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.
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 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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Q f ,
I L
APPLICATION ONLY
ii4s
BUILDING: TYPE'CONST. r�� OCC. GRP.
A.P. Number l 1 -) ) ' 1l I q - S
Legal Description L f:T 3 6L i r1 I
Project Description
Sq. Ft.'r� No. 1 No. Dw. `
Size a� Stories Units
NewA Add ❑ Alter ❑ Repair ❑ Demolition ❑
>timated Valuation
'
PERMIT
AMOUNT
Plan Chk. Dep.
,t../
L[% — f p
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
r
rr
a�
TOTAL
v Y'
REMARKS
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
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760 -771 -8515 -
CERTIFICATE OF COMPLIANCE
r
Date 10/6/00 APN # 774-112-014
No. 21054 Jurisdiction
Owner NameWilliam Thomas Buffin permit # 0010-058
No. 53-575 Street Avenida Rubio Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # 3 - Square Footage 1421
Type of Development Single Family Residence No. of Units 1
Comments
r.`
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 1,421 or $ 2,913.05 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 / Robert Kellogg Telephone
�. Name on the check
By Dr. Doris Wilson
Superintendent /L }
Fee collected /exempted by Annette Barlow Payment Received $2,913.05
• 1 n �� , Check No. 227434
Signature V V
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Districl('s)(s'') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check. application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
w ,
SOIHS-2000. 12400- from-COWNWEALTH1AND TITLE T-518 P,001/001 N24,
RRcaums Raglasm AY:
OLP RFP1BLTC TITLE-COMBACOMBANY �
10348KC 507602-13
WAM RBCORDIM WAT& Tutsi Ds$D AND,
Oa1LESS OTHRRWISR 339OWl1' 'NELOW,
MAIL TAX STAT=a=S TO:
waL�u THOKU SUFFIN
P.O. BOX 134
LA QVINTA, CALIFORNIA 92253
ACR. ABOVE • THIS LM FOR R9C0RD2JV S 092
GRes.W DEED ABDT i 774-112-014-5
The undersigned grancor(s)'declare (a):
Documentary transfer pax is $16.50
(XXX) Computed on full value of roperty conveyed, or
'( ) Computed on full value lea liens and encumbrances remaining at time of sale.
Unincorporazed.area: I ) City of and
FOR A VALUABLE 0ONSIDERATION, receipt of which is hereby acknowledged,
MARVIN L. BOSVELD and DOLORES C. 8OSV9=, husband and wif•
hereby GRANTS) to
WILLIAM THOMAS BUPFSAI-,- AN UPKURIEP MAN -
the real property in the City of LA Q/ RINTA, County of Riverside, State of California,
described as:
Loc 3, Block 191. Unit No. 19 „ Tract Santa CarmeliLa at Vale. ha Quinta, as per map
recorded in Book 19, Page s) 33-39 inclusive of maps. is the office of the County
Recorder of said County.
Dated September 13, 2000
State of California
county of
on
before me, +
personally -appeared
personally knpwn to me (or proved co me on
~Cne basis of satisfactory evidence) to be
the person (9) whose hithe(s) is/are subscribed
Co the within Instrument and acknowledged to
me that he/she/rhey executed the same in
his/her/their autnorit" capacity(ies) and
chat by his/her/cheir."a-ignature(s) on the
instrument the persan(s);.°or the entity upon
behalf of which the•persoh(a) acted, executed
the inozrument.
WITO SSS my hand -'hand official seal. --
Signature
KhZL TAIL STATMOMS TO.-
'd
0:
'd tZ.9.3"ON
MARVIN L. BOSVRLD
DOLORRS C. BOSVELD
Im
(This area for official notarial seal)
SH ICH Xd Nd£Z : Z I OOOZ ' £ l • d8S
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 Contemporary Homes
SITE ADDRESS 53-575 Avenida Rubio
APN 774 - 112 -014 BIN NO.: CASE NO.: 2000-31-3
LEGAL: LOT 3 BLOCK -191 UNIT 14, S.C.@V.L.Q.
CHECKED BY:; Stan Sawa DATE: LZ
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
Compatibility Review
\1
Case logged and number assigned
V
Verify legal and APN information
Consistent with MDG on file (as:applicable
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
Colors
Materials
Architecture
Other Requirements:
016 +D
�62C 1140w4rAyb�fh-')
�J �Lt
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: SFD
Occupancy Group: R3 Type of Consi
Owner of Building: WILLIAM THOMAS BUFFIN
_r•
Building Official
53-575 AVENIDA RUBIO
Bldg. Permit No.: 0010-058
,uction: VN Land Use Zone: RC
Address: P.O. BOX " 13
City: LA QUINTA; CA 92253
By: STEVE TRAXEL
Date: 06-21-01
POST IN A CONSPICUOUS PLACE.