0105-034 (SFD)CV M
Odtto
' LU
O Z t+
O O
H
Iw- as
U)
Z
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 $ of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
;i
�te) Signature of Contractor f•�
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
S� Ion 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 Policy No.
ST.A�'IK f" }ND 01.3'7115408410
(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, nd agree that if I should become
subject to the workers' compensation pro Isioms of Section 3700 of the Labor
Codel J shall forthwith comply with those;pvi?ions.
to i Applicant F 1 -
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, indemnity
& hold harmless the City of La Ouinta, 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 property fq )nspection purposes. i ( `
P1S ature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (j>s TRACT
JOB SITE
ADDRESS
APN
QQ {{�� J�(� ��qq�ppORJYZ
.A-040
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
wf-Ji'l'ARi/B.J LLVCTV
i`C'J)V1.1.';f Pi RAR.Y.H0X0_'
'LA.Q_L;L1.+T'rA CA 42253
(760)564-1962CEtT/ 625
USE OF PERMIT
01) - PhUt'.0411' DOES NOT INCLLfDS BLOCK WAU.&P13rKXIL OR
APPIkfJ,404 l;3F4iVYWAY. MA TRIC 9A.f
714ACA CONO"•'TRUCT AIN 11301..01t SY
PORCH/PATIO 38,00 s?
t3f�1LF1t 1<�L"ARf'Oi °I pr`) 4^80
5 F7WOOD IFFINCE ;Mo. 90 111?
2�''s•L"lW: ) Q"•OrW 01r
FXRKiJ'b'1 T SIMMARY
C'•C73�TLt:PRUCTJON FEE' 101,0{}�►�L38 E�fO 56l2,�dA
PLAN C,HZC'IL".FEE 101 1e
MECHANICAL AL n?,? 101-000,421-000 U0100
lwf,It:l:.TRIC,AL F79 101-000-4:20-000 $Ta1.3t7
PLUMBING pit?, 108 -GOO -419.000 Et10.73
°T3?t)NST MCMIiN F7,9 - f=ID 101-000-241.000 $9.31
K.RApINOME $20.00
D''EV4LJPER1MPACT FU $11YV7.00
P..RF.I."- 39 Pi.I&N 101-000-441-.343 '3100.010
Fiii?' DEPOSIT 10I 0(1J)-4.34 318 $250.110
T'CCiM AN. -D 1sLAN V10WK
$3,4 FA .31
X53HEM
$.250„W7pnDD
r �
1” i°YIVi[ T 1''1+'x!' IALf 'ROW
I:1,� 1 X91
M AY - 4 2001
CITY Of LA OUINTA
FINANCE UPT
R
DATE FINALED
INSPECTOR
NSPECTM RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULDHG
APPROVALS
HECHAHCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
q'
Ducts
Slab Grade
/
Return Air
Steel
Combustion Air
Roof deck
_
�� ( �r
Exhaust Fans
O.K. to Wrap
IJR_ r
F.A.U.
Framing
¢
Compressor
Insulation
_
/l►i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall- Int. Lath
j
Final
(Final—
U'Z—
CB UOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Fina[l
Gas Piping
PC,-U1U1�10Q—JNG APPROVALS
Gas Test
Electric Final
Waste Lines
�ld� $
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
��� �$�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
L�I�' 11164 A?� kIZI
Utility Notice (Gas)
ELECT=AL APPROVALS
Temp, Power Pole
$�
Underground Conduit
�.
Rough Wiring
Lova Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
— - O
Utility Notice (Perm)
—�
Building Q
Address T�
Owner
Mailirsg I
Address p $.a x. l <
%'Ontractor
4P.O.4 BOX 1504 , APPLICATION ONLY
g Z8-495.CALLE TAMPICO
• COfll ! � LA QUINTA, CALIFORNIA 92253 P 10 .
Address
IAlp I rel/
& Classif.'�`1��`�
UL Designer UL
Address
City Zip State
LiO: N
LICENSED CONTRACTOR'S DECLARATION'
I herebyy affiion 3 I ` Ilcensed.under provisions of Chapter9 (commencing with+Sects
7(100) of`Dlvislon 3' uainess and Professions code, and, my license Is � f�ll'fprtc�a 1
effect. r! R
I hereby,affirm that) am exempt from the Contractors License, Law for the following
re880n: (See.-T031.3,Businesssnd Professions Code: Any,chy or county which rapulres a
permit to construct, alter. -Improve, demolish, or repair. any structure, prior Wits Issuance also
requires the appllt:,ant for such perms to file a signed statement' drat he- fa Ikon rs
puuant to
the provisions, of the Contractors License Law• Chapter 9 (oornmencing with Section 70001 of
Division 31 of .t Business and Professions Coda, or that. he Is: exempt, therefrom. and Me.blito
for the alleged exenrptfon.. Any v/olation .of 'Section 7031.5 by 'any epplicent for a perm(.
subjectalhe-appagont to ecivll penahy of not more Mark tive hundred'dollars (5500).
f'! 1, as owner of the property, or my, employees with Wageaas their sole'compensa.1 i will
do the work, and. the structure -Is not intended or offered for sale. (Seo; 7014, Bufanessend
Professions Code The Contractor's License Law does not apply to an 'owner of property who
builds or 1,mproves thereon and who does such wbrk hosel_f of Wrough 'his own employees,
provided !fiat such Lnprovemsnts are not Intended' or offered for sale. 9, however, Me building
or Improvement is sold within one year of completion; the owner -budder will Have me burden
orpronng that he did 'not lwlld'or.lmprovs'forfhspurpose of sale:)
1 1 I, as owner of'the property, am,exctualvely contrecting with licensed contractors to coo-
struct the pfojeet. (Sec. 7044, Bus -mess, and Professlons. Code: The Coefractor's Licansa Law
does. not .apply to en owner of property who builds or Mproves th6reai; and who contracts for
such projects wlfh.e cnnir nktof(s).,C in ed p&muant to tpoe Contractor's Lkoii", ew.)'
17 1 am exempt under Sec. B. 6 P:C. for this reason
Date Owner.
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -Insure, or acertificate of
Worker's.Compensatlon, Insurance, oi,a.certif certified copy then§of, (Sec, 3.800, Lebon Code.)
P I No. Como C o_ r . l
Copyris filed with'the city. � Certified copy Is hereby'furntshed.
CERTIFICATE.OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If Me permit, is. for one nundied• doses ,(S100)valuation
or less.)
1_ certify that in the performance of the work• for which this ,permit is issued, 1 shall not
,employ any- aon r
in any manner as-to,become subject to the Workers',Compensation
Lawn of Ca11Pornirsa. ,
Date Owner .
NOTICE, TO. APPLICANT: N, after makkfg- • Mis ;Certlpcate of . Exemption you should become-
to
ecome-to the.'IAkuhers' Comloensation 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.lorwhich this permitis issued. (Sec. 3097, Clvs'Code.)
Lender's Name
Lender's Address
This is a building permit whenpropedy fllled out, signed and validated, and is subject'to
expiration if work thereunder'Is suspended tor.180days.
I certl}y ihat.l'have read ihis,application and, slate that the above information. is correct.
I
agree 'to comply with ell city and county ordinances land state. laws,. relating to building
construct'on, and he authorize representatives lot this- city to enter the above.
mentioned and
for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
f ,' i
11LDING: PE"CONST:"` j o i>`, OCC: GRP:
P. Number'_
igal Description
oJect Description r 1)
Iq. Ft. (I ` No. I No. Dw.
jiie Stories Units
0 Add ❑ Alter ❑ Repair ❑ Demolition ❑
-,&T- -I� .
I PERMIT I I AMOUNT
Plan Chk. Dep: /`' SV C.`C
Plan Chk. Bal. 1
Const,
Mech.
Electrical
Plumbing
S:M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback,Distances',
Front Setback from Center Line
Rear Setback from. Rear Prop. Line
Side.S'treet Setback from Center Line
Side.Setback from Property Line
FINAL DA
Issued by:
Validated by
validation: APA 18
CITY OF LA QUINTA
WHITE = FINANCE YELLOW =APPLICANT PINK - BUIaqW04UVLqK0LF1NANCE DEPT
01 10:25 FAX 17608049062
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL THIS•QEED AND,
UNLESS OTHERWISE SHOWN :BELOW,
MAIL -TAX STATEMENTS TO;
William Thomats Ruffin
Power Brokers
B.O. Box 1�4-
La Quinta, CA 92253
COMMONWEALTH TITLE 0002
'A —DQd CostT.0,2
SPACE ABOVE THIS LINE FOR RECORDERS USE
The undersigned grantor(s)declare(s): Grant Deed A.P.N. 774-192-002
Documentary transfer tax is $
( x2� computed on full value of property conveyed, or
( '�) computed on full value less value of liens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, , and
Robert & Sylvia Kellogg
hereby GRANT(S) to WILLIAM THOMAS BUFFIN, an unmarried man
the real propertyin the City of La Quinta ,. Count of
Stale of California; described as y Riverside
F
Lot 23s of Block 258 Unit No, Santa Carmelita at Vale La
Quinta, as per map recorded in Book Pages if Maps, Records of Riverside
County, California
Dated April 11, 2001
State of California
County or ) SS.
On before me,
Personally appeared
Robert & Sylv'a Rel�ggq
personally known to me (or proved to me on the basis of satisfactory
evidence) to be the persons) whose name(s) islare subscribed to the
within instrument and acknowledged to me that helshelthey executed
the some In his/her/lhetr authorized capaaty(ies), and .that by
hls/heritheir signature(s) on the Instrument the person(s), or the entity
upon behalf of which the person(s) acted, execuled the instrument.
WITNESS my hand and.of Icial seal.
Signature.
MAIL TAX STATEMENTS TO, Game 4g ab�va
Signature of
Robert. & Sylvia
Form 3196-4 (s-94) THIS FORM FURNISHED BY COMMONWEALTH LAND TITLE COMPANY
1logg
J
Al
In
Case No. 9C ar'`L _`LEL ..�........
xhlbit .............
JN[With Conditbttle .:.,....... ....:.......
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 54-Q40 Avenida Cortez
APN 774 _ 192 _ 00-2. ' BIN NO.:
LEGAL: LOT 23 BLOCK 25,8
CHECKED BY: Wally Nesbit
CASE NO.:
UNIT 24
DATE:
2001-453
S.C.@V.L.Q.
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
COMMENUCORRECTION
Compatibility Review
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file (as.applicable
✓
A5 6V V MP hL&I kes ,w At41L1 -z
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
RECVD FOR -PROCESSING Colors
(DATE)
ASSIGNED TO CCi Materials
(INITIALS)
Architecture
7
V
Other Requirements:
iRroved PAR
Planning Commission..
City Council
Communit Dev. Dept q Z,Mo
Desert Sands Unified School District-
47450
istrict47 950 Dune Palms Road.
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515'
Date 5/3/01
No. 21964
Owner NameBuffn/Kellogg
CERTIFICATE OF COMPLLANCE
APN# 774-192-002
Jurisdiction La Quints
Permit#0105-034
No. 54-040 street Avenida Cortez Log #
City La Quinta zip 92253 Study Area
Tract # BL258 Lot # 23 Square Footage 1.501
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/earports, 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 1,501 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 Calif - Marcus Kellogg Telephone
Name on the check
By Dr. Doris Wilson "
Superintendent
Fee collected /exempted by Arlene Garcia Payment Received $3,077.05
Check No. 7232441
Signature
INOTICE: Pursuant of Assembly -Bill 3051 (CHAP 549, STATS. 19" this will serve w notify you that the 9oaey approval period in,which you may protest the fees or other payment identified I
above will begin lo Fun from the date on which the building or installation, permit for this project Is sssued or on which they are Old to the Districts) onto another, public entity authorized to
collect them on the DistrictCe)(s')'behalf, whichever is earlier.
Collector: Attach, a copy of county or city pian check application form to district copy for all waivers..
Embossed Original- Building. Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
Certificate of Occupancy
City of.La Quinta
Building and Safety Department ovTM
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: 54-040 AVENIDA CORTEZ
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: %R3 Type of Construction:
Owner of Building: BUFFIN/KELLOGG
Building Official
Bldg. Permit No..: 0105-034
VN Land Use Zone: RC
Address:
51-370 AVENIDA BERMUDAS
City:
LA QUINTA, CA 92253
By:
RICHARD KIRKLAND
Date:
JANUARY 23, 2002
POST IN A CONSPICUOUS PLACE