0304-055 (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
iProfessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
1113 VU
. }
,D'ate t� -� }}� 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).
() 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) 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 Policy No. �3fi-G�l12:°-il3ita
(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.
Dafe: 4?- .' '�? Applicant
Warning: Failure to.secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and 'civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
/ Ml
,:Signature (Owner/Agent) t' =yj�•- `f Date t j'✓�''U ,�
PERMIT #
PERMIT
,:..BUILDING . �u4;4 4�:� ;
DATE VALUATIONI r p •9 � 'Q LOT l 4 y TRACT
"
.1 t
ADDRESS rb�-" <�.�? �'F` 4'�s a A4�a� ! � d JOB SITE
APN 'g7046i-021
OWNER
CONTRACTOR/DESIGNER/EN (NEER
'MOMASB5.7.j!.A?I
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SL!4'±v�.''i.l.�$•1.!t]A�J,uiT (`-A, :9.G.�t'01
USE OF PERMIT
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�LAQ�UINTA
PORCH/F. 10— 50.00 .0' CITY OF
f}AkCI}f. L{1� 2�P�`'tJJf�'T 407,00 '."•� FI ANCE DEPT•
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cliwa; nrzc -s) ` � ^ :fit $30.141
mv, DEPOSIT 8 42.04.'00
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tq�PPItt{vAA.&L
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OP0140 )hi OVOR PB - R&SELF 101.0�tl�c0-2-x.� -000
p�n.�
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• ',1,sTIX-1YSE Pl.,tltd
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TOTAL P MeV M DV3 43161A 21
RECEIPT
DATE
BY
DA FIN ED
INSPEC
q.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
,rDATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS * .
Set Backs
— _ O
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
10
F.A.U.
Framing
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 4-p
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
p
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole . p
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) 5
COMMENTS:
-
Date
4/25/03
No.
24366
Owner
Thomas Buffin
Address
City
Zip
Tract #
Type
Single Family Residence
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
Lot # No. Street S.F.
Unit 1 10 51455 Calle Jacumba 1498 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
FlEDk-
BERMUDA DUNES r
V1 RANCHO MIRAGE C7
{� INDIAN WELLS
PALM DESERT ,y
LA QUINTA
J'3OINDIO YJ
O
APN #
770-165-021
Jurisdiction
La Quinta
Permit #
0304-055
Study Area
No. of Units
1
Lot # No. Street
S.F.
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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 1,498 , 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.
Fees Paid By CC/Valley Independent Bank - David Addington Check No. 287140
Name on the check Telephone 760/408-7528
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon MCGllvrey $3,205.72 $o.00
Payment Recd Over/Under
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
CERTIFICATE OF FIELD VERIFICATION AND DJAGNOSTIC TESTING CF -4R
9 3/0 3
Project Title,----
Projed Aress--
_Aral
Budder Cont ct Telephone
i?y/rlo�rr
HERS Wer Talon nna
h's5 4
Name
Plan Number
Sample Group Number
5yKiying Signature / D ale Sample House Number
Firm: S.C. d',gSSOGi �%S HERS Provider: TG.VL A"-dclkfeS
Street Address: .Vj&(TOY4 YC IW Clty/State/Zip: LW Ogle �a' CAL&E,27-3
Copies to: Builder, HERS Provider i
HERS RATER COMP LANCE STATEMENT
The house was; 08Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form
Comply with the diagnostic tested compliance requirements as checked on this form.
Distribution system is fuily'ducted (i.e., does not use,bullding cavities as plenums or platform returns in lieu
,of ducts) '
YJ 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.
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM @ 25 Pa) values
Test Leakage Flow in CFM
-�
If fan flow is calculated as 400cfm/toh-x number of tons enter
calculated value here
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fail (Pass=6% or less)
❑
THERMOSTATIC
Pass Fail
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 Fail
MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
. ❑ 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. ❑ Yes ❑ 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
0 ❑
Pass Fail- ,
i
Certificate of Occupancy
t
T4hf Ot
5�
G� of �w Building Y & 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: 51-455 CALLE JACUMBA
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0304-055
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RL
Owner of Building: THOMAS BUFFIN Address:
City, ST, ZIP:
By: KIRK KIRKLAND
-�
Date: 09-30-2003
Building Official
POST IN A CONSPICUOUS PLACE
l041