0308-315 (SFD)tM f , a
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
n 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
682901 B - � � 12811
ateSignature of Contractor
OWNER -BUILDER DECLARATION
1 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:
( ) A[*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.
W. 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 STA. TB, FUND Policy No. 229- D1I"37-M
(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 provisions of Section 376 of the Labor
96de, I shall forthwith comply with those'provisions. 1,y
/Date: `, //'r:.'� Applicant—
Warning:
pplicant 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, 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 authorize representatives of this City to enter upon
/the above-mentioned propertyfor inspection purposes.
Signature (Owner/Agent),'�� : % ter' �" Dater
1 -
Y
BUILDINGPERMIT _ PERMIT#
DATE VALUATION LOT TRACT.
7 16 c1 1,1S - Ifl WX
JOB SITE
ADDRESS 52-195 AVE, KU1' . JUAM�i7;1"ZCt�.-ri121
APN
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
P.O. BOX 134
41-780 IiERmri'AzF_ 3A
1A CjUl fiT CA 92253
B.. .'V UDA73ta M CA 92201
(160)30,8-7328 MIX 37.24,
USE OF PERMIT i
OR DRIVEWAY APPE0ACH
TRACT CONSTRUCTION I,498.00 V
PORCWPATIO 50.00 SIT
C' tA.RAWCARPORT .467.00 3F
FSUKAM CONI:' OF COl+tSM.MMON'
FERMT FEE SITMM. Y
CONSTRUCTION ION ff-'E 101.000.418.000 SdO:I.si1
`
PLAN CHECK FEE 101,-000-4.3!9,318
ME DE, PO SIT 101.000.439.310 42S9.00
MISCHANICA1. FEE 101-000.42.1-0:10 $59.00
ELECTIrlCAL 101-000.420.001 $110121
Pk.UMBIN0. FEE. 101.000.419-000 $118.00
STRONG MOTION PEE • RROND 101.000.241.000 ' `B9.I2
ORAOINO PEP, lb}'!':tfUO-X23-0qR IS.�10
DEVE-11,0PER WPACT FEES ;?IQS �fl
PRECISE PJAN 101-000-441-345 �ton.vp
."mwm'iXal'TC73 r AND PLAm aRri c
$3,92313
LESS PM PAID 1
P$250,00
r .SEP 16 2003 .64
QTY OF U1 OUINTA
-FINANCE DEPT.
RECEIPT
DATE .4*
BY
D DN
INSPE
o
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
/ o •p
Compressor
Insulation
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 — C)
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
—rj3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
!!27
Encapsulation
Gas Piping
Gas Test
Appliances
Final.
- -
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
Utility Notice (Perm) v
COMMENTS:
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 (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:
#T*P.Aflet►11101U7
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 1,498 S.F. or $3,205.72 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.
I
Fees Paid By CCNIB-David Addington Check No. 287445
Name on the check Telephone
I
Funding Residential -
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia Payment Recd
$3,205.72 Over/Under
1
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
,
PR -15-2004 19:37 FROM:
APR— 16-217H4 lb Y :'L �
0
CERTIFICATE C
AM
Firm; .TC. J- OGi
Street Address! 2Yao q '
TO:564e472
Plan Number
sample Group Number
P.1
r-. W.=.
Samp a House Number
HERS Provider: TG q s
City/5tatwop: Ly Qw/ar _o &?,Z?r'A
Copies to, Builder, HERS Provider
HERS RATER COMUIA14U STA19MENT
The house was; 10 Tested 17 Approved ae part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and Held vorinoatlon, I certify that the houses Identified on this form
Comply with the diagnostic tested compliance requirements as checked on thle form.
V 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 drawbends are used in combination
with cloth backed. rubber adhesive duct tape to Seel leaks at duct connections.
9 MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Duct Pressurizatlon Test Results (CFM ® 25 Pa) Measured
values
Test Leakage Flow In CFM
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 t
Leakage Percentage (100 x Test Leakaga/Fan Flow) v % aP
Check Box for Pass or Fell (Pass=a% or lose)
Fess Fail
THERMOSTATIC EXPANSION VALVE TXV or COMmission-a-pproved equivalent
Yes D No Thermostatic Expansion Valve (or Commission approved
equivalent) Is installed and Aceess I$ provided for Inspection
Yes Is a pass Pass Fail
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
0 Yes O No RCCA Manual D Design requirements have been met
(rater has verifled that actual Installation malates values In
CF -1 R and design on plan.
2. 0 Yes 0 No TXV is Installed or Fan flow hes been verified. If no TXV, NIX
verified fen flow matches design from CF -1 R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass Pass Fail
s�
ertficate of Occupancy
e
roar
a
�oF9 Building & .Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building . Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 52-195 AVENIDA JUAREZ
E
Use classification: SFD Building Permit No.: 0308-315
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: T. BUFFIN Address: P.O. BOX 134
E
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 4=19-2004
Building Offi al
i
POST IN A CONSPICUOUS PLACE
_w _