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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.
License # Lic. Class Exp. Date
Date. 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
1` "
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 3TAT.F,1<':.r0 Policy No. 0.1Mr. 200"2)
(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 k .opt i Fa _ .-o—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in }
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
applicatpon.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for,ins'pection purposes.
f/ s,
Signature (Owner/Agent) �' ter. • �-'••�= "'• Datel-9—j'-'Iti`.�
PERMIT #
BUILDING PERMIT
DATE VALUATIONS 1qV d.�N LOT. } ? TRACTJOB _.
ADDRESS 7i 741490'=..•&A...i. I, �.7H�'.<�JT A�C, L
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
Tjy.)Mf 's ur5'i;'11:1
DAVID L AD,_)H4( 1AA7
RU, 134
41-7so11r," rlo DR
;dnt'+,VMd CA : a -223S
91MM1RADIVIX ,01 C.N MOT;
"7 VjS-7528 C B14 372.4
USE OF PERMIT
1514 S. it. NY,3.4' LiujEzi9'aur 04t;1..t.r01s 131,AJCt, WAL,4 k1.,KJL.0 :
IaRIV9WAV.AFPRIO) (:13, 75%R�'.I',f1 tM) PLAN CRECK R1 FOR M"R1111R,
CONS'R.UC7'1'g918 1,�1�I.p0 NF
CiApl►? 1 ;':�� i`tk�':Al�'P' IT11 , BF
as
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PRRTV IT r,Im SIMM&Ry
C0113T 1X51. -000-x.3 f -.000
PLA14 QHFK.FV it-,
P73MP0,0411 '103-000,439. 18 -$x�j.t,0
hi9C�?.F NIC.AL 1.1,'L- 11)1.m13Gi S2 i-d2P1 �i`s:.itY
S,i.Ef."YRWAi1 VEIL?. R ��9 u�t(9C�- I ;(BGG';) 81 1 1
mu i 0i _000-4I V-fDt't;)
S`f`1?.aN(11VlOTIC%' .VIM - R1t 3ID X S1..
4.23-01)15
GRAUlHOPTZ 101--.0004-25-01)10
i P1tI?,4: E PLAN 1,01-000-441••34 �3UO.J8
:7fJa4."C)`�i,z C1J�;1�fttii"I°iO�T �1i3]I:
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JUN 18 2003
IJ,.
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
DAT NALED
INSPECTOR
INSPECTIO.K RECORD
OPERATION
DATE
INSPECTOR
OPERATION ..
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
— Q
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 7Q-
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
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines44
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral '
Pool Cover
Sewer Connection ,
— D
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) I l/
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) "
FEB-18-2004 09:06 PM _ P.01
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CERTIFICATE OF FIELD 'VERIFICATION AND DIAGNOSTIC TESTING CF-4R
l v
Project Tille Date
�Proae 1 Atl ress
Euilder Name
eui r Cont ct, Telephone Plan Number
HER alar Tele hone Sample Group Number
MO
Cpoyinq Signature Dee Sample House Number
irrrt:.C�' SSG%des HERS Provider; - •�G_� /i�SSeG.
Street Address: 7.yao CItylState/zlp: 6-0 2-5'3,
Copies to:, Builder, HERS Provider
R R TER CQMPIANCE STATeMENI
The house was: Tested ❑ Approved as part of sample testing, but was not tested
A"s"the HERS rater providing diagnostic testing and field verification, I certify that the houses identified on this form
cdmply with the diagnostic tested compliance requirements as checked on this form.
Distribution system Is fully'ducted (i.e., does not use building cavities 'as plenums or platform returns in lieu
of ducts)
!d 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.
illm)NIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT.
Duct, Diagnostic leakage Testing Results (Maximurn 6% Duct Leakage)
Measured
buci Pressurizatian Test Results (CFM @ 25 Pa) valuues
Test Leakage Flow In CFM
If fan flow is calculated as 400cfm1ton x number of tons enter
calculated value here
If fan now Is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow) _57
Check Box for Pass or Fall (Pessw8% or less) ❑
• Pass 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 pe ❑
Yes Is a pass Pass Fail
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
0 Yes O No ACCA Manual 0 Design requirements have been met
(rater has verified that actual Installation matches values in
CF-1 R and design on plan.
2. Cl Yes O 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 =
❑ Q
Yes for both 1 and 2 is a Pass Pass Fail
Certificate of Occupancy
I�C7�
c' OFT19� Building & 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: 77-280 CALLE ENSENADA
Use classification: SINGLE FAMILY DWELLING Building Permit No.: 0305-149
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: THOMAS BUFFIN Address: P.O. BOX 134
City, ST, ZIP: "[Owner Cityl"
fd'1^t By: LA QUINTA, CA 92253
Date: MARCH 2, 2004
Building Official
POST IN A CONSPICUOUS PLACE
.t
ti
CERTIFICATE OF COMPLIANCE �oc Desert Sands Unified School District
47950 Dune Palms Road
Q BERMUDA DUNES
Date 6/18/03 La Quinta, CA 92253 V) RANCHO MIRAGE (�
INDIAN WELLS
No. 24570 (760) 771-8515 �, P LA 0UINTAT y
� INDIO
Owner Thomas Buffin APN # 773-251-022
Address P. O. Box 134 Jurisdiction La Quinta
City La Quinta Zip 92253 Permit # 0305-149
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street , S.F.
Unit 1 11 77280 Calle Ensanada 1514 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
Lot # No. Street S.F.
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 1,514 S.F. or $3,239.96 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. 287276
Name on the check Telephone 760/408.7528
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Shar c ilvrey $3,239.96
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this ill rve 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