0309-020 (SFD)LICENSED CONTRACTOR DECLARATION ,
N 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
C*I W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
�dV7 .
LU 682901 13 1213117(Z r— Date /.j ' ^ Signature of Contractor
CD O
J C-) C:) OWNER -BUILDER DECLARATION
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a 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).
t ( ) . 1, 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
u7 .
N Date Signature of Owner
ON
d Q WORKER'S COMPENSATION DECLARATION
> Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent'to self insure for workers'
XW � compensation, as provided for by Section 3700 of the Labor Code, for the
OQ performance of the work for which this permit is issued.
CD Q U ( ) I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this,
d v Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND Policy No. 220- 001"87-2003
Cb O
J (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. f
/Date: �. � " Applicant / r /Z
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.Safetj;
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 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
f; Y
theabove-mentioned property for inspection purposes.
i' Signature (Owner/Agent) f Date 7 %r• a
BUILDING_ PERMIT PERMI0
ii3dl4-010
DATE VALUATION LOT .j TRACT
JOB SITE
ADDRESS 51-87-5, VEMAD=
APN 773,455.019
OWNER
CONTRACTOR / DESIGNER / EN INFER
'TI-i01IM9 BUITIM
DAM L ADDI2d(,i9 )i
g. Q" BOX 134
41.7801 i . CAGE DR,
LA QMriA CA 92253
BFM&UDA DUNS ` CA 9.201
(760)408.7528 0131- 3724
USE OF PERMIT t
SIDIGr1..1r" .FAMLY DW -LUNG
1914 S.F. SM !i SIMIT DO,E:3 NOT INCIAJDS :BWCiC WALi4 PCIOi SPA
OR I3RArEWAY APPROACH, 75% REDUCED PLAN CHECK F&.E FOR
MULTIPLE PLANS OF SAME TYPE
TRACT CONSTRUCTION 1,914.00 SP
PORCWPA T IO 36.06 .btiF
0ARAWCARROR.T 480.00 3F
TUTS xA3'.�i'➢i:'➢) COSH' OF C:OMMI1CM(?N
113,817.E3C3 '
CONSTRUCTION FFR 101.000.418.0()0 5680.50
PI A34 CHECK FILL 101-060439-3113 $IA3.u�6
FEE DEPOSIT '101-000-439.318 4250M
MECHANICAL, ME 101-000.421-000 463.50
ELECTRICAL 1119E 101 ..=420-000 SIM9
P'I,•UMBING FEE 101-00"19-000 042.60
STRONG MOT1014 FEE - RESID 101-000-241-000 511.35
q3P_& JrN0 FRE X101-000-42.3-000 �Is.aa
DWELOPER II>:TRP.ACti FEE '$2,405,00
PRECISE PLAN 101-0004c11-345 '$IOO.OG
70N'vSTRUCI1011 AND PLAN .C'MCX
$3,696.33
LESS PRR-PAIL F..FZ
4250,00
11%1dMT.1is'] DIT. NOW
S3,4463
FICE
f'.
RECEIPT
DATE
/f
BYE ,�'DA
FI LED
INSPEC RR
(
y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
i MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air I
Steel
Combustion Air
Roof Deck /- .p
Exhaust Fans ;
O.K. to Wrap
F.A.U.
Framing
Compressor '
Insulation
Vents I
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 i
Footings
Main Drain !
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping f
PLUMBING APPROVALS
Gas Test
Electric Final i
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
Encapsulation
Gas Piping
Gas Test _ v
Appliances
Final i
COMMENTS:
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 (Penn) C9 -
I
Certificate of Occupancy
LIM
G OF g YDepartment
Building & Safety
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: 51-875 AVENIDA DIAZ
Use classification: SFD
Occupancy Group: R3
Owner of Building: THOMAS BUFFIN
—.4, /4-v'
Building Official
Type of Construction: VN
Building Permit No.: 0309-020
Land Use Zone RC
Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 5-25-04
POST IN A CONSPICUOUS PLACE
MAY -24-2004 08:26 PM
TI
Firm:.1,G. d' f4Gi S
Street Address: _7��� &-Yd End �2�
Copies to: Builder, HERS Provider
HERS RATER C.QMPUANCE STATEMgN
TE
U81 • � .
Builder Name
Plan Number
Sample Group Number
Sample House Number
riamo rrvvlder:
Clty/State/Zip; Lu0(r 06 G"69_gy&o
P.01
CF -4R
The house was; Tested 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
cam with the diagnostic tested compliance requirements as checked on this form.
pistribution system is fully'ducted (i.e., does not use building cavities as plenums or platform returns in lieu
to
gyof 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.
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM t@ 25 Pa) values
Test Leakage Flow In CFM 1a1
If fan flow is calculated as 400cfm/ton x number of tons enter ,,
calculated value here_
If fan flow is measured enter measured value here
Leakage Percentage x Test Leakage/Fan Flow) = " 0
(100
Check Box for Pass or Fail (Pass=6% or less)
❑
Pass f=ail
THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
es ❑ 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
t , 0 Yes 0 No RCCA Manual D Design requirements have been met
(rater has verified that actual installation matches values In
CF -1 R and design on plan.
2. O Yes 0 No TXV is installed or Fan flow has been verified. If no TXV,
/ (•/�
0 verified fan flow matches design from CF -1R.
Measured Fan Flow = ,
O �
Yes for both 1 and 2 Is a Pass
Pass Fail
ifs