0107-343 (SFD)LICENSED CONTRACTOR DECLARATION—
'_'%hereby affirm under penalty of perjury that I am licensed under provisions of
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class Exp. Date
d L
Lu
r Z r1_ Date Signature of Contractor _,��JA4_-
CID 0
J U �'-•.,.._ ..,r -"OWN' ER=BUILDER-DECLARATION
W d I hereby affirm under penalty of perjury that I ar i exempt from the Contractor's
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 rof-the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals.
Code). -
- C'') () I am exempt under Section B&P.C. for this reason
LO
OC\1 Date Signature of Owner
rn , '
Q . • - WORKER'S COMPENSATION DECLARATION
p zcc I hereby affirm under penalty of perjury one of the following declarations:
Lo P O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w I= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver Policy No.
O STATE FUND W UNIT 00:..1094
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 Vovi Ions of Se tion 3700 of the Labor
3 Code, shall forthwith comply with tho a provisions.
Datee7, t 9 Applicantr�
Warning: Failure to secure Workers' Cof pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf, this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
Y permit, or cessation of work for 180 days will subject permit to cancellation:
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fo4nspection purp ses.
1
Signature (Owner/Agent) Date t -2-`2 __04
BUILDING PERMIT PERMIT#
DATE ✓J�� VALUATION LOT (5�}°f�p�}TRACT
JOB SITE
APN
ADDRESS
M AVEI+11„l3As lliMMRAt
775-A:aQ-010
OWNER
CONTRACTOR/DESIGNER/EN (NEER
11130M:AS BYlF` X
PAZ fCCiMr1'RMMON CO
52•,.995 AVKHIDA.1WDOZA
52-M AM+MAMENTDOZA
1,. k QUINTA CA 9=3
I„A QU2k;MA CA 92253
(760)5(A-3023 V4 5537
USE OF PERMIT
R—NOIX, ?143�/CSL' 1�itV S
SFO, - PXXMT.t` DOF.,9 NOT tMCWOF BLOCK INVAI.,1, POOL, OR. DRIVEWAY
APPROACH. 9A' NAS't R 84.
TRACT CONSTRUCTION ION 1,481.011 SF
PC7;i,.L"ki1WA'I TO 36.00 SF
CIARAGEMARPORT 5iuo SSS
5 Yr. WOOD FENCE 10.0 LF
M1.SJl.9A+wd.�L3NJCR2O
on'Our+.7e..JS4:
�(ggyy��YY������(r,pp``�p..yy gg'��ygy�,, A2•q�q,Q•���+�E$Ap7d,P.kN'Y�'K�.JY.�9D4...L.�9�L'01F
,T.Wr.RG.6Y.r1L.4 dr IS L'i4T..faWµDQi8.7iM1Y$
COMMIMMON ME 101 -OW -41,8-000
P1&k1(11i1EIC-'flC 1�ri:E� 2.04 �f1tt03_'1 ¢gat►. t
l+ECHAWCA>aFRE 101.000.421.-000
aP. rCTI CA11 VVIE $ 29A4
P III W'i01�u17 101-000¢419=000 4110-W
.
STM3idO MOTION RZ - RESIN 1101-000 241-000 W9
01'f O .FEB • 101-f 00-423.000
11FVZWPP1R W. pArly FEB
'i'RWISie, PLFb2'1 101.1000 1 ': 45 � 11t�4.G3ti
101-000A.' .' �3O.OfS
AUG 23 2001
+wt lxq[Rxy l f:) , AND INTA
4X-50.00
' LY.+.14R1Lf� .g MGYFJ �.1 9 DIM'NOW
RECEIPT
DATE% BY
� . ��.A),
DATE FINALED
INSPECTOR
r.,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_
5
Underground Ducts
Forms & Footings
� .�
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-O C
e-�
.� • -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
jp_3 _ d C
s7
Compressor
Insulation
!� t'o - o (
S7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 14
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
p _
�28`�=1
_
Heater Final
Water Piping
O
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2♦$ - p(
S.Z
Encapsulation
Gas Piping
Gas Tit
_
Applia�e
�.
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
_
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
_ /
_ Y
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
/ f<
Utility Notice (Perm)
u
Aj�'
P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address S3 — 2 ova i (1.w7�: f2 LA QUINTA, CALIFORNIA 92253
Owner
Address �� cjS LSU _fin
City Zip ITel.
Contractor
71>-Z_
Address
City Zip Tel.
—5c> sr>"
State Lic. City
8 Classif. 5 51 Lic. #
Arch., Engr.,
Designer
Address Tel.
Zip (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. 7031.5,8usiness and Professions Code: Any city or county which requires a
permit to construct, after, 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 ($500).
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 or 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.)
I l 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 7 I 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 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. 0 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 ($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, alter 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 stale 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 prop art y for inspection purposes.
Signature of aQplicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number ��� — t"��Q oI c)
Legal Description C -r, -r I, G to «! 2 1r1
Project Description O u , -2-
Sq.
Sq. Ft. No. No. Dw.
Size , 2 j Stories 1 Units
New Add ❑ Alter ❑ Repair ❑ Demolition ❑
QP, (2 -
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
2S
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property -Line--- -
FINAL DATE
'� INSPECTOR f '
{"
r Date
Issued by:
1 j Permit
j JUL 3 i 2001 'tt 1
I a
Validated by:
!!!
I
Validation:
t
t
I'e� y, i4i1 Uj irl,il
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 8/22/01
No. 22406 Jurisdiction
Owner NameThomas Buffin
No, 53-200 Street Avenida Herrera
City La Quinta Zip 92253
Tract # Lot # 15
Type of Development Single Family Residence
Comments
APN # 774-054-010
La Quinta
Permit # 0107-343
Log #
Study Area
Square Footage 1421
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 detennined 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
2.05 X 1,421 or $ 2,913.05 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
n
Fees Paid By CCNalley Independent Bank - Augustine Paz Telephone
Name on the check -
By Dr. Doris.Wilson
Superintendent
Fee collected /eaemp ed by Annette Barlow
Signature
Payment Received $2,913.05
Check No. 247685
JOTICE: Pursuant of Assembly 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
ibove will begin to run from the date 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
ollect them on the Districtrs)(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
_
/09/61 ^10:25 FAX 17608049062
,.. .
RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TO:
William Thomais Buffin
Power Brokers
B.O. Box 134
La Quinta, CA 92253
_............... _.... _... _:....... ....... .......
. .
CO:1I110N\ VEALTH TITLE
0002
w'�r
SPACE ABOVE THIS LINE FOR RECORDER'S USE
The undersigned grantor(s) declare(s): Grant Deed A.P.N. 774-054-010
Documentary transfer tax is $
computed on full value of property conveyed, or
( t) computed on full value less value of liens and encumbrances remaining at time of sale.
( ) Unincorporated area; ( ) City of and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
JUDY MEYERS
hereby GRANT(S) to WILLIAM THOMAS BUFFIN
the real property in the City of La Quinta County of .Riverside
Stale of California, described as
Lot 15 of Block 217 Unit No. 6�4 , Santa Carmelite at Vale La
Quinta, as per map recorded in Book Pages mf Maps, Records;of Riverside
County, California
Dated July 23, 2001
State of California
County of
On before me,
,personally appeared
JUDY MEYERS
personally known to me (or proved to me on the basis of satisfactory
evidence) to be the parson(s) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed
the some in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the Instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature
MAIL TAX STATEMENTS TO, sa�ae T1s ahovo
Signature of Grantor
JUDY MEYERS
-Form 3195-4 (6-94) THIS FORM FURNISHED BY coM NWr—at T141 enin Trn c rnnnnniv
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 house design does not duplicate the same architectural style of any
house within -2'00 feet ofthe 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
transmitted this information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT PAZ CONSTRUCTION 57y*7.-� ("AscK ) S -
SITE ADDRESS 53-200 Avenida Herrera
APN 774 - 054 - 010
LEGAL: LOT 15
CHECK AND APPROVED BY
CASE NO.:
BLOCK 217
Wally Nesbit
2001-536
UNIT 21
DATE:
S.C.@V.L.Q.
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
V117 i r=7 &,,v/ --
Consistent with MDG on file (as
applicable
MDG filing required (5 filings since
9/3/98)
rt(, JSf
Architectural variety within 200 feet of
the surrounding area: .
?
use?- P� alvA
Colors
Materials
Architectural design features
ll
v
Approved by;
vao
Other RequireS®ning Commission
O City Council
° (Communit Dev. Dept.
.�----
�--:-
Initials
Case No. 13 GO
Exhibit
HiQ
7
L
7
Certificate -of Occupancy
City of.,La Quinta
Building and Safety Department � OF "
A
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, .at the time of issuance, this structure was in compliance with the various ordinances
of the City -regulating building construction or use. For the following: - .
BUILDING ADDRESS: 53-200 AVENIDA HERRERA
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R-3, U-1 Type of Construction:
Owner of Building: THOMAS BUFFIN
Building Official
vni
Bldg. Permit No.: 0107-343
Land Use Zone: RC
Address: 52-995 AVENIDA MENDOZA
City: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: DECEMBER 19. 2001
POST IN A CONSPICUOUS PLACE