0309-017 (SFD)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.
682901 13 1 12/31 /:K
Dater 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 o construct ��the project (Sec. 7044, Business & Professionals
Code). f .7
( ) I am exempt under Section B&P.C. for this reason
Date `.Signature of Owner
,,PORKER'S COMPENSATION DECLARATION
J
I hereby affirm under p natty of perjury one of the following declarations:
O I have and; Iwl I-mantain 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 STAT1? FUND Policy No. X29- 00197"-2003
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.
/Date: Applicant f j
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
o & 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
O 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.
/J d r l
Signature (Owner/Agent) f Date' -
PERMIT #
BUILDING PERMIT
,#
DATE -VALUATION - LOTTRACT <.
.c - i � .a $11.4A34.20110._ "...... i� S 210
r i .: ,,
JOB SITE
APN'• }. '., ? %.
ADDRESS 53-4255 3Ui�'i NH0'iA'MZ DEL
ti&
OWNER ,
CONTRACTOR /DESIGNER / EN INEER
MOMAS BUMN'
DAV'1:13 d.,. AT. DaT(YrON
P.0. BOX '134 '
41-79t11;3E°11atiT';ACM DR
LAQTJXrA CA - 92253
RMMA.DiJ, ES CA 92201
1
(-160)408-7528 Cr"- 3724
USE OF PERMIT Y
4WCiU, 1?AW..Y T)VffLI.3Z3'C1' "a • .
19.58 S.F. SPO P01=1 , DOES'NOT 11.4 1,UDZ SUCK Wi'hi. , POOFJSPA.
OR DRIVEWAY APPROACH ;
TRACT CONSTRUCTION ION 1918,00 SP
PO. WHIP.ATIO 36.00 3F
QA A,OUWARPORT 4-80.00 SY
ESMA7,MD C0117f OF L7O.LY1v'J.`.91`13MTOM
114,034.20
PERmn, ITIE 9I7AM&Izy
CONSTRUCTION ME 101-000-418-000 $692,00
PLAN CHECK FEE 101-00011439-318 $371.84
FM DlilyOSIT 101.000.4-39-318 42%60
I011 N, AN9C�tL I<HE 101 _000-d21-0'4 9.40
811FICTRICAI, PER 101 _000.00.000 $12.5.23
PLUMBING FEE 101-000-419-000 $124.00
STRONG MOWN FEE - WIND 101.000.241-000 $11,40
MADINQ FiE 101 -000 -423 -?.0 $13.00
.
DWI LOPER IMPAC ME
PRFC13Z PLAN 101-400-.44,1-345 s100.0p
STJB 'To- ,.co.womw=014 RNID PIAK CTffrK..
94,103.45
} LESS M -PAM FFY.V
-5250,00
O�EAjs 1I���' TMEN Dtr1i- HOW
Z,MA;
,SEP 16 1003
CITY OF LA-QUINTA R.
RECEIPT
/
D TE FINALED
INSPECT R
A:.-1"
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
, c7 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
u
Drywall - Int. Lath
Final
Final
o
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground EWctric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines *
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
f��A�'D IfaM'tP Gf'LTt �,ft�GjlGG �i %3�
i
Final
Utility Notice (Gas) i
ELECTRICAL APPROVALS
Temp. Power Pole (j
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles.
G.F.I.
Smoke Detectors
Temp. Use of Power i1 d
Final
Utility Notice (Perm) ;
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District z4�c
47950 Dune Palms Road
Q BERMUDA DUNES r
ANCHO
Date 9/16/03 La Quinta, CA 92253 R INDIAN WELLSE
ALM DSERT
No. 24976 (760) 771-8515 �� PQUENTA �y
%INDIO y,
Owner
Thomas Buffin
APN #
774-085-022
Address
P.O. Box 134
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit #
0309-017
Tract #
BLK 210
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street S.F.
Lot # No.
Street S.F.
Unit 1 10
53425 Eisenhower Dr 1918
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments
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 1,918 S.F. or $4,104.52 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. 287439
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Yolanda Garcia Payment Recd
$4,104.52 Over/Under
Signature '
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 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
APR -16-2004 07:27 AM
CERTIFICATE OF FfELD VERIFICATION AND
Project Title o:
Proiact Address
I3U
r E
rifyinq Signature p to
Firm:.7~C.
Street Address:
Copies to: Builder, HERS Provider
no
STING
WOWy�
Builder Name
Plan Number
Sample Group Number
CF -4R
Sample House Number
HERS Provider: _ _TG_� Awcl&s
City/statealp: _La tic la:g C!9 '7;2,5r3
HERS RATER CQMELIANCE ITATEMENI
The house was: XTested ❑ 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
corrIply with the diagnostic tested compliance requirements as checked on this form,
(O Distribution system is fully'ducted (i.e., does not use building cavitles aess plenums or platform returns in lieu
of 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.
2 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+
If fan Flow is calculated as 400efm/ton x number of tons enter
calculated value here
t
If fan flow is measured enter measured value here
Leakage Percentage (100 x Test Leakage/Fan Flow)
Check Box for Pass or Fal! (Pass=6% or less)
❑ ❑
Pass Fail
Lir—THERMOSTATIC EXPANSION VALVE (TXV) or Commission approved equivalent
iYes ❑ 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
i . D Yes 0 No ACCA Manual D Design„requirements have been met
(rater has verified that -actual. Installation matches values In
CF -1 R and design an plan,
2. 0 Yes ❑ No TXV is Installed or Fan flow has been verified. If no TXV,
a�l
.verified fled fan flow matches design from CF -1R.
Measured Fan Flow
-
❑ C]
Yes for both 1 and 2 is a Pass
Pass Fail
O
,- Certificate of Occupancy
4 �.?. L.aaetoim�
'YCJy,, roes
C OF'IBuilding & 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: 53-425 EISENHOWER DRIVE
Use classification: SFD Building Permit No.: 0309-017
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: T. BUFFIN Address: P.O. BOX 134
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 04-22-04
Building Official
POST IN A CONSPICUOUS PLACE