0201-120 (SFD)LICENSED CONTRACTOR DECLARATION
II hereby affirm under penalty of perjury that I.am licensed under provisions of
y 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
16920 �a / �9�, 03i91f�(
Date ��.. Ph;- 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). `
O 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 +�`f:A°i�. FUND Policy No. 1�t�11L�• tfft�l
Q (This section need not be completed if the permit valuation is for $100.00 or less).
J . O 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 3700 of the Labor
Code, I��shall { >fo�rt�h�with comply withItliose provisions.
JDate: lam— ApplicanFr� y',
=,Warning: Failure to secure Wo a 's 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. v
IMPORTANT Application is hereby made to the Director of BLilding and Safety
for a permit subject to the conditions and restrictions set fo.rfh ,on his,
application.
1. Each person upon whose behalf this application is made '& erson at
Whose request and for whose benefit work is performed under p suarr��tl1�to
any permit issued as a result of this applicaton agrees to, & s , i derd�ifly�
&'hold harmless the City of La Quinta, its officers, agents an er 1ployees.
�t 2. Any permit issued as a result of this application becomes II and Vjf ftf®
work Is not commenced within 180 days from date of issu nce* of so Or
permit, or cessation of work for 180 days will subject permit to Cance la lot n.
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 property for inspection purposes. !
Signature (Owner/Agent;,, ? Dater f✓'.8
BUILDING PERMIT PERMIT#���
DATE %} ` f VALUATION $93,(M. -yo LOT 10 TRACT
<Z.41 U23
JOB SITE 'sn4-7 .c� ��s MD :�+AVA�i�.�a.�O APN 77-414-02.�
ADDRESS
OWNER
W
CA 92253
USE OF PERMIT 1
,r PPROACNWA,S ' k4IJ.,s`, ,
CONTRACTOR/DESIGNER/ENGINEER
I,& O'YIM. A CA 97,253
"'(760)564»196* CLIQL10 6255
MACT t" ONSTR C:TI(M OF
P01 GIVIPATTO jig. 00 :k?
GARtA,C!PMA1k1AO1ZT 46100 0
51 T. WOOD Fr1gCE 290.09) LF
EffrWAUM COFir OF COMFM1C°':['.!(€
N
p—`RKTr Na SUAM1+1 'RRy
EE
CONSTRUCTIONpf��
101-pC�1{00.41 1!
.;�ak.
6�.��1"l;��h.,K feir.�1'.�
tBy-ii00
10 itw000-4d Y9-31 )
�T90t"
.p5..1.:
MECHANICAL VF1v +.
" 101.000.421,000
1>a
:,:yy'xCC7fi@@�yy,yCA.11_11 Fyf Z
W1. -00.0,-&p 20y-�ty�00
$131
yFAXr
Y41�,6J,tl1.fJiNG .t' R.'.E �'
1011 00+J1pw1'.i:9-000
SA1
S d'11.C: NO 7��t7�`Ft�2d PER, • '�iF'S1',D
101-000-241-000
so
4iZt1DINO FEE
101.000.42:14100
V
1�1�!'f.�I.O;P�1t. IMPA+-VOT 'ice
i't�k..C1.31, MAN
10'1.000.441-�45
St
1" z i3 POS1T
101 •�E 00-439-3 18
d.SO
i.45
A.CD
30
0,�
0,00
0x.00
(10.f31
tt.OA
sr
I li TOTAL;(,*O ds'%ftlT:l-""rl g.Ak4D PT AM C.°EMCrX`, I3,.464 3
8 24002
l�Q�ll�°" 3,y;; TA.L :1,?1 �t•1?I�3'�` FEES :�+ TE ►�' .W ;��.431
rFMTIIT
V '
RECEIPT DATE f w BY ( "� DATE FINALED INSPECTOR
sr
I li TOTAL;(,*O ds'%ftlT:l-""rl g.Ak4D PT AM C.°EMCrX`, I3,.464 3
8 24002
l�Q�ll�°" 3,y;; TA.L :1,?1 �t•1?I�3'�` FEES :�+ TE ►�' .W ;��.431
rFMTIIT
V '
RECEIPT DATE f w BY ( "� DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
, d j�-
Compressor
Insulation
- p?✓
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 7 0
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Y� �'a--
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)
COMMENTS:
0
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
Date 1/28/02 APN# 774-134-020
No. 22864 Jurisdiction La Quinta
Owner NameRobert Kellogg/T. Buffin Permit #0201-120
No. 53705 street Avenida Navarro, Lag #
City La Quinta Zip 92253 Study Area
+ Tract # BLK241 U23 Lot # X10 Square Footage 1501
Type of Development Single Family Residence
Comments
Tract Construction 1501 sq. ft. ,
No. of Units 1
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 it 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 may now be issued
+
Fees Paid By CC/Union Bank of California - Marc Kellogg Telephone `760-333-5390
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Nicola Wong
Signature
Payment Received 2:877.05
Check No. 7688452 .
NOTICE: Pursuant to Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may prot9st 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 m another public entity authorized to
collect them on the DisOrict(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
,SAA
co?iDSONWEALTH TITLE
RECORMNG-REQUESTED BY;
AND w.,4EY RECORDED MAIL.TMI&DEEO AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAK"STATEMENTS TO;
Robert Kellpgg
53 -Io5 Aq aatDA 0,242.0
SP.40E A90VE THIS Ll4-g FOR RECCfiCER's Uat3
t
Grant Deed A.P.N.1 779-1 3�-020
The ,Undersigned,grantor(s) deoiere(m);._
Doaur entary lydeisfpr ax l9
computed on fuW4ue of prope,ny conveye'l, or
computed ori fill value leswvaiue of liens and encumbrances remaining at tlrria of agle.'
1 Un7neorporated area; ( ) City of and .
FOR A VALUABLE= CONS10FRATION, receipt of which Is hereby, "acknawled8ed,
JESUS -8, BRENDA FLORES
hereby ORANT(S, to ROBERT KELLOGG , a marxted ,man. as %-jai 'soje and .aepara'te property
the"real props, y In the City,of La Quinca" County of. Riverside
State of Califomis. desot ed as
10 10 of Bleck 241thi t No, 23 Santa Urueli a •at,Vale fa 4uinta,
as per map reccrded, i"n 13octC Pages � dtf Maps; Records, of;Ri-irside Cour.Ly,
Cad ia y
Dated November 29; 2001 Signature of Graninr
Slate of California )
County -of )S5.
On
JESUS & BRENDA FLORES
betorp-rite, � �
-personally appeared,
BRENDA FLO
per9ohally known b me ;o, prbvOd to iilp on the basis of 9atlsfattory
_.
.vidarce) to be -the person(9) whosa name(s) Ware gulbacdl:ad to the
wltNn Inatrument and,fcknowtedaed,tc me that ha/s:he/shay exmied _
the atvrne, fn ' hJai herYtheir outhortied, wpdc;ty(fes), and thei - by'
hlafr,er/thelr siQnatu a(r,)_'ar tie IASINMenl the pe,moa(e), or the entlty.
unch behalf of*w, I'tichthe Per 9on(s) pciad, sx®wu►ad the Inatr:,ment:
WITNF-§$ my hanq�ano official seal,
5i®nstuts
',MAIL TAX STATEMENTS ?'0,----a-—��Avm-- a
I
d! .07,:x.9'°N Sd1111Cd9 6No;d :N l
RC DISTRICT - PLANNING REVIEW FORM+.
This form is to be used by. CDD staff for review of single family, dwelling- 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 Epplicant 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 Contemporary Homes
�fr
SITE ADDRESS
53-705 Avenida Navarro
APN 774 - 134 - 020 CASE NO.: 2001-594
LEGAL: LOT BLOCK UNIT '`j/ S.C.@V.L.Q.
CHECK AND APPROVED BY: Greg Trousdell DATE.:
Inform the assigned Building plan checker upon your assignment to this case. The CDD
Executive S tary maintains a log book t-o/track a 11ications an�ig� case numbers.
REOUIRED ITEM
Y
N
COMMENT/CORRECTION.
Verify legal and APN information
/}
"Consistent with MDG on file (as
applicable
Ao409
MDG filing required (5 filings since
9/3/98)
Architectural variety within 200 feet of
the surrounding area:
b O O Of
se
M
Architectural design feats
b
A �'
G
a�e�
s
Other Requirements:
N
+�
r
JUL-09-2002 08:59 PM
-INSTALLATION CERTIFICATE
P.03
DUCT LEAKAGE. AND DESIGN DIAGNOSTICS
DUCT LEAKAGE REDUCTION
Pressurization Test,Pesults (CFM @ 25TA)
Test Leakage'(CFM)
Ian Flow R
II' Fan Flow is Calculated as 400 cfm/ton x number of tons, or.as 21,7 x -Heating Capacity
/
in Thousands of Btuliu, enter calculated value here
If fan flow is measured, enter measured value here
Leakage Fraction = Test Leakage/(Measured or Calculated Fan Flow)
Pass if leakage fraction 5 0,06
❑
Pass
❑ For .AEROSOL TYPE SEALANTS ONLY - The following diagnostic testing was completed:
.Fail
'
Duct Fan Pressurization at rough -in measured leakage (CFM)
`
CHECK AFTER FINISHING WALL:
❑ Yes ❑ No 13 -Pressure pan test or House pressurization test
❑ Yes ❑ No ' ❑ Visual Inspection of Duct Connections /' ❑
❑
' Pass
,Fail
{
' THERMOSTATIC EXPANSION VALVE (TXV
Yes ❑ No, Thermostatic, 'Expansion Valve (or Commission approved ,
equivalent) is installed and Access is provided for inspection'
[�
Yes'.is a pass Pass
Fail
❑ DUCT DESIGN -
.
I' ❑Yes ❑ No ACCA Manual D Design calculations have been completed—
Duct
Duct Design is on the plans and duct installation matches
plans.
2.
TXV is installed
❑ Yes ❑ No or Fan flow has been verified, if no TXV, -
verified fan (low matches design from CF -1R,
Measured Fan Flow
~ Yes for both I and 2 is a Pass Pass
�,. .
Fail
- ❑ 1, the undersigned, verify that the above diagnostic test results and the work I performed associated with the test(s)."
cunfomlance with the requirements for compliance
in
credit. (The builder shall provide the HERS provider a copy of the CF -6R
sigmed by the builder employees or sub -contractors certifying that diagnostic testing and installation rneet the requiremcnts for
compliance credit.)
'Test
11tr( Signanre, Date Installing Subcon actor (Co: Name) OR
Nerfurmed
General Contractor.(Co. Narte)
COPY TO: Building Department:
HERS Provider (if applicable)
Building Owner at Occupancy
JUL-09-2002 08:59 PM
.CERTIFICATE OF FIELD VERIFICATION AND DIAGNOSTIC T
Project Title
P. 02
CF -4R
Project Address Builder Name
Bulkier Conta tJI Telephon§L Plan Number
E S Rater
H
A. Telephone Sample Group Number
fying Signature D to Sample House Number
Firm: HERS Provlder:��-
Street Address: 4&424 City/State/Zip:
Copies to: Bullder, HERS Provlder
tMRS RATER COMPLIANCE SMENT
The house was: Tested ❑ Approved as part of sample testing, but was not tested,
As the HERS rater providing diagnostic testing and field verlflcation, I certify that the houses Identified on this form
comply with the diagnostic tested compliance requirements as checked on this form.
' Q3""Distrlbution system Is fully'ducted (i.e., does not use building cavities as plenums or platform returns` In lieu
t,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.'
P -MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT `
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Duct Pressurization Test Results (CFM Q 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 �e7
N fan flow Is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _, , I.A
Check Box for Pass or Fail (Pass=6°% or less)'` []
Pass Fail
THERMOSTATIC EXPANSION VALVE TXV or Commission approved equivalent
tr Yes l ❑ No Thermostatic Expansion Valve (or Commission approved
equivalent) is installed and Access Is provided for Inspection
Yes Is a pass Pass Fail '
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
'1 O Yes E3 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.
2• 4 Yes D No TXV 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 ail
City bf 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: 53-705 AVENIDA NAVARRO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0201-120.
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: ROBERT KELLOGG/T. BOFFIN Address: P.O. BOX 134
City: LA QUINTA, CA 92253
By: RICHARD KIRKLAND
Date: , 07-15-02
Building Official
POST IN A CONSPICUOUS PLACE
1