0304-273 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
w„ Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
LO
w� 6> 2901 F3 'f ^ 12/31/2(
oZ r Date Y 7.c-+-� Signature of Contra0.ctor ✓_
CD
rf— o OWNER -BUILDER DECLARATION
CID
W a I hereby affirm under penalty of perjury that I am exempt from the Contractor's
IA License Law for the following reason:
Z_ ( ) 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 tc construct the project (Sec. 7044, Business & Professionals
't Code).
( ) I am exempt under Section , B&P.C. for this reason
LO
C\; Date Signature of Owner
C 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 STATV FUItE) Policy No. 279.001"87-W- 3
(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 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:' � - Applicant
'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 property for.inspection purposes.
Signature (Owner/Agent) / �` � _-= Date `- . 2 ✓ .7
's= BUILDING PERMIT PERMIT#
DATE VALUATION LOT 03042273 TRACT
$87,12. 3 BTX 234
JOB SITE " ` ' APN
ADDRESS . 3-305 .+AlfiaWA VALLFiCl 774-M-015
OWNER '[CONTRACTOR / DESIGNER / EN (NEER
T.giO9raAT31I3+ 1 D A.VM L PDDINGION
PD. ;BOX 134 41-780. a _' &TAC B M
LA QUINTAP, OA 92233 .MMUDA DITM CA 92201
(-760)�08.75U CI3.T,3t 3724
USE OF PERMIT
1400 S:ld'. STI) P31 WIT 131023NC1T NCL,UD&B OCIC WA1A,'POOLS OR
DRIVEWAY APPROACH. 75% REDUCED PI:AN CHECK FEE 1W.MULTIPLA
PL AM S..kM.%TYPE,
TRACT CONSTRUCTION L403..00 8F
PORCHIPAa tib 36.0 Srr
t3A1iA:C#WARPO.RT 920160 BY
EGnM AITM COOT OF COI3'STRIUCUO
PFAZM rte: RUAWARY
CONSTRUCTION EEE
101.000.418.000
089130
PL,A14 CHECK PER
lc'31-OCirJ••4'39- 38
$122.43
Ems. DEPOSIT
101.000.439-318
42$0.00
MECHMZICAI.
101.000-.42.1-000
$53.50
11.1! CTItiC'At,1
101.000.420.000
5100118
PLdlIb1SYHO FEE
101-000.419-000.
$124.00
STA,0140 MOTION FEE - RMID
101 -000 -241 -OW
$8,71
t7:RADINO FEE
1,, 01-000.423-000
$115.00
DWELOPER, IMPACT 1vEE
37a403.0
PRECIse PLAN
101-000-4.4.1-345
• $100.0(1
87',125.20
SUB -TOTAL �RUCIMC?N: ANDD '•ClMM
LEV PRE-1PAWFF ; $250.00
P?EES DUE .NOW
RECEIPT ____;.-'DATA BY DATE FINAL D INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
— p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
—
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
— - Q
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 — 2
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
_
Pool Cover.
Sewer Connection
Encapsulation
Gas Piping
Gas Test
$ 03
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 G
Utility Notice (Perm)
COMMENTS:
T4ht 4 4 Q"
P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address —3G�� ilAl I E'Td LA QUINTA, CALIFORNIA 92253
Mailin
Address �i �� as X /3 �� I
C &410 IZIp /�ITeI.����
contractor , //�
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Ad ss lG
/- 716 1fEleD�d1 /�A�i,
p q,).Q 0/_
I I ei.. [ 6?1
State Lic *City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000)
t.of Division 3 of the Business and Professions Code, and my license is in full force and
effec
SIGNATl1RE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,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 penalty of not more than five hundred dollars ($500).
L", 1, 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 I 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 contractor(s) licensed pursuant to the Contractor's License Lew.)
I'! I am exempt under Sec. B. 8 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
C7 Copy is filed with the city. 0 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 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.
Date Owner
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
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 it work thereunder is suspended for 180 days.
1 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 sof this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
03dJO.273
APPLICATION ONLY
03C941'"'? mace -VO
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number T7y__ 00p R _ /0/ � /
Legal Description 60 7- 3 �C 1K_ z;713 !7
Project Description 1.iT
7 5920 EE
Sq. Ft.No.
Size yO Stories
New ❑ Add ❑ Alter ❑
Lstlmate0 valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
No. Dw.
Units
Repair ❑ Demolition ❑
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 = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE
r�
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road -
Date 5/22/03 La Quinta, CA 92253
No. 24451 (760) 771-8515
a
D
� o
Q BERMUDA DUNES r
RANCHO MIRAGE
{�J INDIAN WELLS
PALM DESERT y
LA QUINTA
�INDIO y� "
" O s
Owner Thomas Buffin APN
Address P. O. Box 134 Jurisdiction La Quinta ,
City La Quinta Zip 92253 Permit # 0304-273'
Tract # BLK 234 Study Area
Type Single Family Residence i No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 3 53305 Avenida Vallejo 1408 Unit 6
Unit 2 Unit 7
Unit 3 Unit8
Unit 4 . Unit 9'
Unit 5 Unit 10
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:
• EXEMPTION NOT _APPLICABLE _
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 1,408 S.F. or $3,013.12 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.
Fees Paid By CC/Valley Independent Bank - David Addington Check No. 287198
Name on the check Telephone 760/408-7528
Funding Residential.
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by SI
Signature
McGilvrey
$3,013.12 $T_00
Payment Recd Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), tRil 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 Distnct('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant ' Copy - Applicant/Receipt . Copy'- Accounting
RC DISTRICT -PLANNING REVIEW FORM
This form. is to be used by CDD staff Jor 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 housing 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 applicant to file for Master
Design Guidelines. If the applicant does need.to.file a Master Design Guideline, please transmit
this information to the Building and Safety Department as part of your correction list. Please
attach additional explanations as necessary.
APPLICANT:
SITE ADDRESS:
APN CASE NO..:���
LEGAL: LOT BLOCK UNIT S.C.@V.L.Q..
CHECK AND APPROVED BY: 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
Consistent with MDG on file (as.
applicable)
MDG filing required (5 filings
since 9/3/98)
Architectural variety within 200
feet of the surrounding area:
Architectural design features
D
roved b . Date Rescue#
tanning Commission ---_
(nit
--Gem-
ommunityy Dev. Dept. ,
als�t/I/M
ibit ,fir
Conditions
Ext
O VVith
Other Requirements:
�- Certificate of Occupancy
o
f
G� OF9ti Building & Safety Department
1
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
P
construction and/or use.
F
} s
BUILDING ADDRESS: 53-305 AVENIDA VALLEJO
iBuildin
Use classification: SINGLE FAMILY DWELLING 9 Permit No.: 0304-273
x
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
F
Y
M
� l
Owner of Building: THOMAS BUFFIN Address: P.P. BOX 134
City, ST, ZIP: LA QUINTA, CA 92253'
"— By: KIRK KIRKLAND
a'�
e e
Date: October 22, 2003
v E
Building Official
POST IN A CONSPICUOUS PLACE'
,OCT -17-2003 07:04 AM
Projekt Title.,
Builder Name
,
Plan Number
Sample Group Number
• P.04
tyihg-Sig nature ate Sample House Number
Firm: HERS Provider;
/ -, r
Street Address: 7 �i'7 OY I CitylState121p, G W h
Copies to: Suiider, HERS Provider
HERS RATER COMIsLIAN E ST16TEMENT
The house was: Tested. C3 Approved as part of sample testing, but was not tested
As the HERS rater providingg diagnostic testing and field verification, I certify that the houses identified on this form
co ly with the diagnostic Cested compliance requirements as checked on this form, ;
Distribution system is fully'ducted (i.e., does not use building cavlties •as plenums or platform returns in lieu
7f ducts)
here cloth backed, rubber adhesive duct tape is installed, mastic and drawbands are used in combination
witn cloth backed, rubber adhesive duct tape to seal leaks at duct. connections.
9�-MINIMU.M REQUIREMENTS FOR DUCT,LEAKAGE REDUCTION COMPLIANCE CREDIT
0.uct=Diagnostic Leakage Testing Results (Maxlrrtum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values,
/
Test Leakage Flow in CFM
If fan flow is calculated as 400cfmlton x number of torts enter /
here
calculated value
If fan Flow is measured enter measured value here
Leakage Percentage (100 x Test LeakagelFen Flow) = 7 d p
Check Box for Pass or Fail (Pass=6% or less)
ass Fail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
`Yes -❑ No Thermostatic Expansion Valve (or. Commission approved
equivalent) is installed and Access is provided for Inspection
Yes is a pass
Pass Faii
❑ MINIMUM REQUIREMEN'T'S FOR DUCT DESIGN COMPLIANCE CREDIT
1 D Yes 0 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. C Yes Cl No TXV is installed or. Fan flow has been verified. If na TXV,
verified fan flow, matches design from CF -1 R.
Measured Fan Flow =
Yes for both 1 and 2 is a Pass
Pass Fait
4