0309-019 (SFD)} LICENSED CONTRACTOR DECLARATION
U), I hereby.affirm under penalty of perjury that I am licensed under provisions of
�F– Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cit W Professionals Code, and my License is in full force and effect.
O License # Lic. Class Exp. Date
LLI
66901 B,' r 12t1`c
oZ r� Date! 14 Signature of Contractor LY
O." /
J U C) OWNER -BUILDER DECLARATION
W UJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
CL
U) 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 to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section B&P.C. for this reason
LO
O a Date /--*� -" "Signature of Owner _..
d Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of, perjury one of the following declarations:
' `r O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W+— compensation, as provided for by Section 3700 of the Labor -Code, for the
0,._ J performance of the work for which this permit is issued.
m J• v<
Q U ( ) I have and will maintain workers' compensation insurance, as required by
O Q J Section 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation insurance carrier &policy no. are:
Carrier ;STATE FUND Policy No. 229- 41019787-2003
aco
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,
1 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'
3 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-'/
1.
PERMIT#
BUILDING PERMIT
•
DATE.j& ''`VALUATION LOT � � � TRACT
**�7 JJ/l /9 fi�it�►,i B.tPD 22 13LK 217
�n
JOB SITE "
ADDRESS AV..l`LDA� �A
APN
1'74 USk 0'28
OWNER
CONTRACTOR / DESIGNER / EN (NEER
THOMPAB Bill TW
Jn
LAVH L.AJD.DWWON
P.O. BOX 134
41-780 [�is.I�M1T.AGE TSR
LA QUTAI"iA CA 922.53
F91rE22 TODADT NES CA 92201
(760)408.7528 t!Pajg 3724
USE OF PERMIT
i
SWGL' V, FA iit. Y T)MIALLTHO
1948 S.P'. ",FT) PERMIT DOES NOT INCLUDE BLOCK WAL1, POWSPA,
OR D i'V EWA,Y APPROACH
TRACT C0142TRUCTION U411.00 8F
-
PORCHIPPA rIO 36.00 SF
C.lARAWC.A RPORT 193.40 OF
E�ya'xi1�7Ci.!'D COW GF tC-C11�'!9'.11FC.t'1'aal'Y,ON
p�r�^� ypvp� y;�;y�� L Ay
.1.�jR.IYI.I.Jt.' J7,.f GIUMI�eO.i.Q..(.
CONSTRUCTION FEE 101-000418-000.
PLAN CHECK T475r, 101 _000-439-31 E $585.68
P19 DEPOSIT 101.000.335-318 4150.00
NI CHANICAL FEE 101.000-4.21-000 $59.00
KECTRIC'.AL TBE; 1031.-000.40.000 $130.54
PLUMBING FEE 101-000-419-000 $12A.00
STRONG MOTION I,1: - RF.3ID 103-000-241-000 $11,98
43RAOINa NEL 101-000-42.3-000 $15.00
DEVELOPER IMRA(:T FEE 944000
P REICISE PLAN 101-000.441-34.5 $100.00
ff0B-T(YTAL C0Ni ;Gi(.'M0NT AND I.a,L.M CHECK
,$4,140,10
ZFZ3 FIRE -PAD) FMS
-$250.00
IA% 1^F0 T FEEES DMF 14 OW -
93,690.711
SEP 16 2003
jT
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE
BY .�`�
DAT FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS •
MECHANICAL APPROVALS
Set Backs
—Y az
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
/ - to
Exhaust Fans
O.K to Wrap
—
F.A.U.
Framing
7
Compressor
Insulation
Q
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
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
A -m ,g7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection—,Vo—
-
Encapsulation
Gas Piping
Gas Test
. O
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 ( o -57
Utility Notice (Perm)
COMMENTS:
Building
Address /T V
T4tyl
"
P.O. BOX 1504 APPLICATION ONLY
'I 8-495 CALLE TAMPICO
LA
K QUINTA, CALIFORNIA 92253
r
Mailing
Address
City Zip _Lt 7 Tel.
Contractoe n
Address
/
� ✓"
City
Zi
ri1
Tel.
C, Cj
Side Street Setbac _Center Line
Side Setback from ertyL n —
Sta a Lic.
I CTOR
Issued by:
City
& Classif.
/
V?L G
Validated by:
Lic. #
Arch., Engr.,
FINOF QUIN
Validation:
rA
Designer
Address
Tel.
CityI Zip I State
Lic. #
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 the alleged 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 (8500).
L: 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
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.)
1-1 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 Law.)
I'] I am exempt under Sec. B. & P.C. for this reason
Dale Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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
n Copy is filed with the city. O 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 (8100) valuation
or less.)
I certify that in the performance of thg 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: It, 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
Ihereby 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.
I certify that I have read this application and slate 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 -of this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant Date
,Mailing Address
City, State, Zip
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
i
BUILDING: TYPE'CONST.S,�C4OCC.
GRP. r�
A.P. Number" 7 / y0, -L / f ^ 02-. '
Legal Description Lc, -A- d,_2 wK ,?,/77
Project Description
Sq. Ft. /n � 1 �4L No. No. Dw.
Size l�`1 �l �J �Stories Units
r Add I] Alter O Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setbac _Center Line
Side Setback from ertyL n —
FINAL DATE
I CTOR
Issued by:
Dateit
1
03
Validated by:
FINOF QUIN
Validation:
rA
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
Date 9/16/03 La Quinta, CA 92253
No. 24968 (760) 771-8515
Owner Thomas Buffin APN #
Address P.O. Box 134 Jurisdiction
City La Quinta Zip 92253 Permit #
QC BERMUDA DUNES r
V) RANCHO MIRAGE t=I
INDIAN WELLS
PALM DESERT y
LA QUINTAV
QINDIO `^
V O YJ
774-054-028
La Quinta
0309-019
Tract # BLK217 Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F.
Unit 1 22 53080 Avenida Herrera 1948 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 1,948 S.F. or $4,168.72 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 CCNIB-David Addington Check No. 287442
Name on the check Telephone
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia
Signature 1�
Funding Residential
Payment Recd
$4,168.72 Over/Under
NOTICE: Pursuant to Government Code Section 66020(d)(1), this Will serve to notify you that the 9D -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
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for 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 '. % l - 05 -LI - G ay
LEGAL: LOT );)' BLOCK
CHECK AND APPROVED BY:
CASE NO.: 9B
UNIT
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
Approved by: Date Re
13 Planning Commin-c1c)n
so #
11 Pity Council
12"Community Dev. Dept.
1 4404
Case No. Sw I_-B&L-
Exhibit &O- _ �+
.11 With Conditions
Other Requirements:
JUN -10-2004 04:43 PM
TION
Plan Number
Sample Group Number
Sample House Number
�j / rider: /e: C, d' /9 g -t odZI
Street Address: 7W lo AIL444AOf I,W4 s. City/State0p: M rk
Copies to: Builder, HERS Provider
HERS RATER C MPLIAN EJITMCMENT
The house was: Tested ❑ Approved as part of sample testing, but was not tested
As the HERS rotor providing diagnostic testing and field verification, I certify that the houses identified on this form
eorn with the diagnostic tested compliance requirements as checked on this form.
EZ Distribution system is fully ducted (I.e., does not use building cavities as plenums or platform returns In lieu
9�of ducts)
.Whero Cloth backed, rubber adhesive duct tape is installed, mastic and drawwbands are used In combination
with cloth backed, rubber adhesive duct tape to seal leaks at duct connections.
P.01
CF
MINIMUM REQUIREMENTS FOR DUCT LEAKAGE REDUCTION COMPLIANCE CREDIT
Duct Diagnostic Leakage Testing Results (Maximum 6% Duct Leakage)
Measured
Duct Pressurization Test Results (CFM Q 25 Pa) values
Test Leakage Flow In CFM VY
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 (100 x Test Leakage/Fan Flow) 7r
Check Box for Pass or Fail (Pass=6% or less)
Q
Pass Fail
L EXPANSION VALVE; (TXV� ar Commission s�proved equivalent
- - ��_
_ �THtERMOSTATIC
21 Thermostatic
Yes ONO Expanslon Valve (or Commission approved
equivalent) Is installed and Access is provided for inspection
[)
Yes is a pass
Pass Fall
❑ MINIMUM REQUIREMENTS FOR DUCT DESIGN COMPLIANCE CREDIT
1, 0 Yes ❑ 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. 0 0 No
, Yes TXV Is Installed or Fan flow has been verified. If no TXV,
verified fan flow matches design from CF -1R.
Measured Fan Flow =
0 0
Yes for both 1 and 2 is a Pass
Pass Fall
Certificate of Occupancy0 o
r�
Lcn�wnhn 41
isa G1'
G� OF'Tk�9� 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: 53-080 AVENIDA HERRERA
Use classification: SFD Building Permit No.: 0309-019
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: THOMAS BUFFIN Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: STEVE TRAXEL
!mob' Date: 6-14-04
Building Official
POST IN A CONSPICUOUS PLACE