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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
Professionals Code, and my License is in full force and effect.
LicenseW%57 I c. Class 1/ f E /p1D1tAM/98
Signature of
' OWNER-BUILD�R DECLARATION— '
I hereby affirm under penalty of perjur �h t 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 37db'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:
Carrierf;tJldD Policy No. IyF(4OR-93
(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%p ecome subject to the
workers' compensation laws of California and Fee that if-1'should become
subject to he workers' compensao provisions f�S ("tion 3700 of the Labor
Code, ] II fo - j ith comply wi . those 0. 'si n
.,,-Date: I y Applin, l
Warnin :Failure to securekers' Compensation coverage is unlawful and
shall subject an employer to6criminal 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 thabthe above information is
correct. I agree, to comply with all City, and State �aV1s relating to the building
construction, and hereby authrorizqq' represent�ti sof this City to'enter upon
the above-mentioned property or i1spection f o s. }
11
Signature (Owner/Agent) t K, Date
BUILDING PERMIT PERMI!).40 219 .
DATE VALUATION SJ 181n6-10 LOT 12 TRACT' - 4�.'049114
JOB SITE 5]-395 A.VC; N1DA IDLKZ
APN 773-043-026
ADDRESS
OWNER -
CONTRACTOR/DESIGNER/ENGINEER .
TRONA, AS BUE.FM
jOE W. �1" `uNfh11?11 11:.. CQ*�,j9r.
PO BOX 134
-3'2335 WASHINGTON S.1'. 055
LA Q7I3II rA CA 92253
PALM DES RX CA 922.11
(760)360-9365 C13x # 2,119
USE OF PERMIT
KNOLF FAMILY WELLING
74.85.3 VEL1E WY 1sl!
r
uk �.!'�ttiL'11.0 ilJl.,rSat� 1Y171 i1Vt,;LLJ1Ut:,#SLVt.:h YVi1i,l.� VKYVVt.. ,
iTACTC��iV'litii T:Giv 1,4()3.x'+0 SF
PO.RC'HAWr10 ;. :1248.00 ST.
Gl4:[26tUDCARPEiWr 313.00 :3F
6 FT. 'WOOL) FFINCE 200.00 z a:
i
• i?i�XIShUC IOasiOt4A416afi4a
1.��71.PO�Y. aftl
COld;3'IR C"I'.1U1N FEE 101-OW^418-000 �+7ui.4J0
RLAN CH CK FEE 10! 4,M43 -3 18 Shc� 2r
AWr'Ha1i°1ICAL FIES 14x1.-telali�<Isaa lU +{/ y�1(i.{ii.%
ELCICITR.TCAL.I'LE 101-000-3 "00 $176,37
s
`•I'1.1)iV12SINO '.F)3E 10.1-000-41.9-000 $145.50
wmIRONc31NiQ'f3'0N FEE - ICES Cy i0! -000-24'1-00x1 $1.1.84
ORAIa:CN'C3 IrW 101-000-423-000 520,110
YN1'RA; 'i`t2UCT'URA M. u25�000443-342 52,551,22
PR.ECISF, PLAN 101-000-44:1-345 $25.0)
ART IN PURUC;: PLACES - RES.tC 7014M -155 -mi i VS,Tf
FRE DEPOSIT 101-00,434-3.19
SUM-3YYT"AL• C'OM';°'I R CTTION AND PLAN CHECK
$4„342.16
1 BLESS hRE-PAIDFEES
4250.00
RECEIPT
DATE
i
BY
DATE FINALED
-
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade A
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. K. to Wrap
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
POOLS - SPAS
BLOCKWALL APPROVALS
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 zxe A4Heater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Paris
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
'Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Zm
Final
Utility Notice (Gas)
-ELECTRICAL APPROVALS.
Temp. Power Pole :
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
.'Main Service
% Sub Panels
'.Exterior Receptacles
.,G.F.1.
..Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
C I/
E
Building
Address 5-1 ~ ,
Addres
y . o X l
s /J
CityZip
1741-1TA I A2
Contragtor 1 jA�w
Address �/
p A6ooB,e,W Xd
City Zip
c&ty/ 4 4 Q" q�05 -.216t
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
"Z LA QUINTA, CALIFORNIA 92253
State Lic. City
& Classif. I Lic. #
Address\ r I Tel.
] It /ZGJi l e/ .. I • w i►
e IC .A I I✓./x/t7if JIZIr1 1�1 /� ILic. t#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE 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 live hundred dollars ($500).
I', 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, 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
orimprovement 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.)
( 1 1, 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 contractorls) licensed pursuant to the Contractor's License Law.)
1-1 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
In Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is tot 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 WorkersCompensation 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 if 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. Q
Signature of ap
Mailing Addres
City, State, Zi
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 773 - 043 - n 2 <P
Legal Description L 12� 4f u+
.
Project Description S. / . �
Sq. Ft. No. No. Dw.
Size (j Stories Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
t
ZONE: BY:
Minimum Setback Distances:k,
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Property Line
FINAL LCE` - INSPECTOR
Issued by: 9,��, "Date -Permit
Validated by V
Validation'.
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
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 11/19/98
No. 18018
Owner NameThomas Buffin
No. 51-395 Street Avenida Diaz
City La Quinta
Tract # B49 U4 Lot # 12
Type of Development Single Family Residence
Comments
APN # 773-043-026
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area
Square Footage 1,903
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 in the amount of
1.93 X 1,903 or $ 3,672.79 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed projeevinay now be. issued
Fees Paid By CCNalley Indendent Bank/Joe W. Stemmer Jr. Telephone,
Name on the check ==
By Dr. Doris Wilson r•''
Superintendent
Fee collected /exempted by Juanita Green Payment Received $3,672.79
W Check No. 177046 .
Signature
NOTICE: Pursuant of Asse b Bill 3081 (CHAP 549, STATS. 1996) 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 begirt to run from th dale on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Districts 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
03 '98 05:44PM CUSTOMER SERVICE
HICAGO TIT! C COMPANY
>:0RDIXG REQL'ENTEU aY:
+464Y
,Nil N•t1t:� tttWORDH:) ?IAIL THIS nISFt) ASO. "
t'NI.rss OTHERWISE. S1ICW% nFI,O W
MAIL TAX STAT"tEWS TO.
The Kel'103_& Revocable Trust
Robert B. Kellogg. Trustee
P.O. Bos 9249
La Jolla. CA 92039
0'7944'7
AECEIVED FOR RECORD
AT 2:00 O'CLOCK
MAR 10 1997
p.,aas
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' Grain Deed A.P.N. rteyersi- see attached
The undersigned grantor(s) deela«(c): -- - -
Docurncntary transfer tax is S -0- is
( ) compulcd on full valuc of property cont•cycd, or
( ) comruted an full value less talue of liens and encurn!trcanecs remaining at time of sale.
{, ) Unincorporated arca. ( ) City of and
FOR A VALUABLE CONSIDERATION. Nreipt of..•hiclt i5 h, rely aclno vl dxed.
STFRLINC IIMMS, a California General Partnership
twoly GRANT(S) to
ROM= 8_ K>311 W0, Trustee of the Kellogg Revocable Fa)aily lust
the real pn+pert.• ;n ncc Cite of i Quiarn acrd . Coant` of Riverside . S1a1� o CuliforniJ. Ja .a ril+ad a,
Cathedral City
G Sib EX112BIT 'A' IITIACSMp WR1EY'O FOR A CMU%M LEGAL DESMIPTION
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By: Lend e Ventures. Inc., a fornix Corp.
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JORGE SHMEN and ASSOCIATES
0
F 74854 VELIE WAY
sL7TE u5
4? PALM DESERT, CA. 92260
0 (760) 340 3528
(760) 340 3728 FAX
® E-MAIL:JSEPTIEN@AOLCOM
January 13, 1999
CITY OF LA QUINTA
BUILDING AND SAFETY DEPARTMENT
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA , CA. 92253-1504
RE: Single Family Residence
Thomas Buffin
51-395 Avenida Diaz
La Quinta, CA. 92253
TO WHOM IT MAY CONCERN,
Recently I visited the subject project's job site in order to observe the adherence to the architectural
design reflected on the construction documents that my firm prepared. At that time I observed the project to be in
substantial conformance with the design intent of the construction documents. I therefore state that, with regard to
my observations, the noted project is in substantial conformance with the design intent of the construction
documents I prepared.
If you have any further questions regarding this or any other matter with regard to the subject project,
please feel free to contact me.
Sincerely,
Jorge Septien
Design Consultant