9704-057 (RER)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
397975 E3 7/31./913
'/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):
O I am—exempt under Section B&P.C. for this reason
Date ,w Signature of Owner
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.
( ) 4have and will maintain workers' compensation insurance, as required by
Sec ion 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 Policy No.
STr11",r.PUN D 2294M037.115
(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
bode, 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. a
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 information6s
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 upogY
the above-mentioned property for inspection purposes. °r
Lignature (Owner/Agent) Date
e:
B�I�DI�w PERMIT PERMITq _ CONTROL# �.:p
(fid=1 PERMIT 111YII 9710"5 2Y5. Qt
���ddd
DATE VALUATION 14367.719.`11) LOT t TRACT X691JOB
SITE
ADDRESS 55-515 OAK HILL
OWNER
CONTRACTOR/DESIGNER/ENGINEER ,
ftALPHcaWMEWICt 1
KA:NcIA0LA.PiS`M.Ar4c rev tcPMt`lT
15:370 BtiRKANC A Pkwy
79"7 COUNMY CLUB :�. R #201
IRV9:NE C'A 9271.3
BERML(DA. DUNES CA 92201
(760)3.5.175.5 C13110 1969
USE OF PERMIT
SNI.;
r3H) •-1'r221MFf` DORS:! OT 4IdE""i, TIE 4LOCK IWAL .S OR POOL
CUSTOKi x::C:i'ri i•e"R.(3G°i"l0IN 4,357.003F
POR61441A.'1'ICt 450.00 SF
`.
<oA�2.A419:ift 'Af2Cjt alt i' 1,1,39.CA) S,F
TIM` EKill C`t� T70fe CONISTR FCT ALON
367, 719.70
1�'(yNSI`f21JC'"!'tC3:R� Ir.%Yi ll?i-1;110-4:111-�Oti 5;;57'J.St�
.
PLAN Q41W,-K, RM tO1 •-000-439•118
1VlFC1'IAN:lCA f % .... 1:01 -000 -421 -Wo $.155.01)
&I;C IRICAL FFE 101-400-420-000 6674.28
3�I•,tlMf3iTdt3''N-1?E I0t.=000 41.9-011(1 $2,15.75
:3'rONG MOTION FIFE% - REIS.1Ila 101-000-241-000 136.`';7
Cli2MNNO FER 101-000-4.23-000 4;2C1.Ox)
eI,NFtZrl.�lIRUC,"CVk3.I FFIG 225-000-443-3,f2 .ifilO:�rU
RT Iii PUP!ACtai., g(` -,3 -Rtjfr, 711):-0130-?Tti*O $66930
e
A
SUB-TMAL CONSTRUCTION AND PLAN CHECK
$10,239,02
fio%L11 PRE -PAID FEES
-$1,000:04 .:0
•
1991 OrAL1'11:It1!(d r F i.ES DUE rdCbdi
$9,239,02
0'
' -'A 6
,lk
i
SOL 1 .
RE
DATE.
BY
DATE FINALED
INSPECTOR
E -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
E INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts t
Forms & Footings
Ducts f
Slab Grade
Return Air I
Steel
Combustion Air f
Roof Deck
Exhaust Fans E
OX to Wrap
6
F.A.U. i
Framing
Compressor [
Insulation
/
Vents 1
Fireplace P.L.
Grills I
Fireplace T.O.
Fans & Controls l
Party Wali Insulation
Condensate Lines [
Party Wali Firewall
I
Exterior Lath
S
Drywall - Int. Lath
[
[
Gyv f
7
Final [
Final
— —
POOLS - SPAS
BLOCKWALL
APPROVALS
steel t
Set Backs
Electric Bond I
Footings
Main Drain t
BqpA Beam
Approval to Cover I
Equipment Location f
.�
Underground Electric I
Underground Pibg. Test E
Final
Gas Piping 1
PLUMBING APPROVALS •
Gas Test t
Electric Final {
Waste Lines
L
Heater Final I
Water Piping
Plumbing Final !
Plumbing Top Out
Equipment Enclosure i
Shower Pans
O.K. for Finish Plaster I
Sewer Lateral
Pool Cover
Sewer. Connection
Encapsulation E
'Gas Piping
{
Gas Test
$ -
Appliances
[
Final I
COMMENTS:
Final
Utility Notice (Gas) c — 2 —
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 -
vFinal
Utility Notice (Perm)1167- .�
1
Coachella, Vatle'p-00fied"School Mstrict
P.O. Box 847 1 CA— 92,274
Thetmia,
(619) 399;51317-`--,Eit. 235
Project Name:.
Owner's Name: Ralph- 0 #k
Address: 55-575x,Qa Oa
k-,
Project Description: S i -no _,,1 'e, -,
This Boi For District Ilse Only
DEVELOPER FEES PAID
AREA:
AMOUNT: RCPTA
M, M QUM
INITIALS: DATE:
CER—T—
(Government. Cod3*0'80)-
PWI.:cz
Date: June .4. 1997
Thone No. 345-7755
APN: 769-350.015 4Tract #: 269531 Lot #:'
Type of Development: Residential
ial XX Commercial Industrial
Total Square Feet of Building Area: 4357
Certification of-Applic - aht/Owners: Tlie.person,sigmiig,..'cdrtifies thAt.the above information is correct and makes this
lWt* �, , ., d:.
statementement under pe perjuryan fiudier reOrdsents� hels ri
P .. to e owner/developer.
Sigliatire::,
Dated:
SCHOOL DISTRICT REQUIREMENTS FOR -THEABOVEPROJECT HAVE BEEN OR WELL BE
k*J`
SATISFIED. -IN ACCORDANCE WITH 4 FOLLOWING. (CIRCLE ONE):
Gov. Code Gov. Code Project Agreement -Existing Not subject to fee
53080/65995 65970 Approval ;prior-. to 1/1"/87. requirement.
Note:
Number of Sq,/Ft. .43W
Amount per Sq/ft. 1..84
Amount Collected $ 8,016:88'
BY: Foch "Tut",-Pensis. Assistant Superintendent Administrative Services
Administrator in Charge
Certificate issued by. Marcela Valdez Sighature:-.MAIV17 11UA
Facill,:00 -ULir,k-*.
NOTICE: Section 66020 ofthe Governiuent Code enaacd 308!; t forth 6'(??pter 549 !6,effi�;�e 4�]L 4'.1997, recptires that this school distinct vide �.,"Awfifll S, �;'Stat� of S;tite ofWornia6 1q. bvi(� =notice
to
ce
die project applicant at die We Upipient 9fichoo!fiem,'initiption payment or. laieiexi�tions. This notice is to advisc'�6u dmf protestin regud to stich amounts or the validity thereofin !cc I section 6020
other applicable WW, c9ini - f - I . � " described in Section tikk of Govenunelit Code. Additionalty, no that die
ofthe (lovenunent Code ' and nences with in��i4rnent 6r perfonnance don);.�th�a requimnent as .0
protest themofinust occur within 90'6alendikdays thereafter.
Note: AB 2926:and SB 201 fees are capped it $1.84 per, square foot for: all residential construction, and at $0.30
per square, foot -for comm'ercial/industrial. projects. -
Dev. Fees Disk: Misc\Cert-ComSam. (REV. 1/97)
z,Aprz-22-97 08:54A R. O-zorkiewicz
714 731-7338
-
061880
RECORDING REQUESTED BY
DECEIVED FOR RECORD
AT 8:00 O'CLOCK
AND WHEN RECORDED MAIL TO:
Russell G. Allen
2 51997
O'Melveny & Myers LLP
610 Newport Center-Driv'
$Uite. 1700
Rowdo In Official Ro=da
Newport Beach,•CA .92660
•
41fvglvsiaecamb.camorria
Aff Re�rder� v
Fees S
"(Space Above for
ASSESSOR'S PARCEL'NO.<769 51-020 and
769=350-015-,.4' .
TRUSTTRANlSEER DEED
The undersigned grantors declare:
Documentary. transfer taxis $ =0- (See _ NOW Below) .
[ ; Unincorporated area: [X] City of La Quint*, and
iL
FOR NO CONSIDERATION,; LPH L :KZOZREVC. KEWICZ, hereby GRANT to �1tit c
RALPH L 0;wRI 6WICtInd, ARIE: C 'OZORKIEVNICZ, and their successors, as Trustees W the
Ozorkiewlcz Living Trust datn-171111.— , the;following describecJ rea( property in'the City of
La C3u66, County of Rlverside; State: of California:
Legal description attached 'hereto as,,Extilb t A and Incorporated herein by reference.
NOTE: This conveyance transfers the interest of`grantors into _a revocable,trust of which the grantors
are the sole bene�,�c666 and is not a change: of ownership under�Revenue and .Taxation
Code;Ssctfoni,52. There is: -no documentary. transfertax:dud, ,Revenue and Taxation Code
Section 11911:
�.� u /
DATED: �:, 1996; .
RA . H' L KIE►N(CZ
Use
ti
P.02
MAIL TAX STATEMENTS`TO:
Mr. and Mrs: `Ralph l::Ozorkiewicz
La •Quinta, CA 92253
1,181.281288N1
,Aer X 22 - 97 08:54A R Ozark i ewA cz 714.'731-'7338 P. 03
G18!®
STATE OF CALIFORNIA )
COUNTY OF :ORANGE )
On efore,me •, ALLEN a,..Notary Public in and
for said State,. personallya,appeared RALPH L...OZORKIEWICZ and MARIE C OZORKIEWICZ, personally
known to:me',(gc:proved`to mean the basis,bf satisfactory'_eviderice) to,be the, (s) whose name(s)
is/are subscribed to. the"wittiln instrument and acknowled`g'ed tome that he/she%ttiey,executed the same
In his/her/their authorized capacity(Ies), and that4byihis/her/them signature(s)„ onthe instrument the
person(s), or the entity upon ehalf: of -which the person{s). acted,`executed the instrument.
WITNESS my hand and official seal. .
` Ca;.
Signatur (Sea!) 'Norryr: 4:.,.. -. .ttr;. •.
Luce COL94rr
my c. ici. ".WueeAug 13. IM
Apr'-Ozorkiewicz 714 731=7..338 P.01
618190
EXHIBIT A
PARCEL 1:
A CONDOMINIUM COMPRISING:
(A) AN UNDIVIDED 1/12TH INTEREST IN AND TO LOT 3 OF TRACT'N0:.26953, IN THE CIN OF LA
QUINTA, COUNTY OF'RIVERSIDE,`STATE'OF CALIFORNIA, AS PER _MAP.flECORDED IN BOOK 236
PAGES 56 THROUGH 58=INCLUSIVE OF MAPS; IN 7HE OFFICE' OF.THE COUNTY RECORDER OF
SAID COUNTY. � � .
EXCEPT THE UNIT8,I-39'THROUGH 1-50,�INCLUSNE AS: SHOWN'ON THE CONDOMINIUM PLAN
RECORDED .:ANUARY 24,':1992- AS -INSTRUMENT"NO: 26549, OFFICIAL RECORDS.
(B) ,UNIT 1-41 AS SHOWN ON THE CONDOMINIUM` PLAN RECORDED::JANUARY 24, 1992 AS
INSTRUMENT NO. 26649, OFFICIAL RECORDS.
SAIDCONDOMINfUM IS SUBJECT, TO.THE- ;DEC
LARATION OF COVENANTS, CONDITIONS AND
RESTRICTIONS FOR; :P:G.A.' WEST, RESIDENTIAL'PROJECT,,RIVERSIO,E COUNTY, CALIFORNIA
RECORDED JANUARY 22, 1986 -AS INSTRUMEfVTNO fi5570, IN THE,OFFICI'AL RECORDS OF THE
COUNTY RECORDER'OF SAID COUNTY, AND ANY AMENDMENTS OR SUPPLEMENTS THERETO
('THE DECLARATION°): AND' THE DECLARATION YAND .APNY AMENDMENTS ,OR SUPPLEMENTS
THERETO ARE4INCORPORATED HEREIN AND MADE`A'PART=HEREOF BY THtS`REFERENCE.
ALSO EXCEPT.ANDRESERVING TO. THE GRANTOR ALL OIL.AND;GAS,. HYDROCARBON AND OTHER
MINERAL RIGHTS BELOW 560:00 fEET:BENEATH THE SURFACE'OF SAID LAND, WITHOUT RIGHT
OF SURFACE ENTRY. `
PARCEL 2:
LOT 2 OF TRACT:26953'14THE CITY OF.LA QUINTA, COUNTY -.OF RIVERSIDE, STATE OF
CALIFORNIA, AS PERM "RECORDED.IN' BOOK 236, -PAGES 56 THROUGH 58lNCLUSIVE OF MAPS,
IN THE OFFICE OF"THE COUNTY,RECORDER.
{
PROPERTY ADDRESS (PARCEL 1): 55-671 OAK HILL
APN 769-351-020 LA QUINTA;-CA 92253
PROPERTY ADDRESS. (PARCEL 2): 55-575:.OAK HILL
APN 769-350-015-4 LA QUINTA, `CA _92253
N81-291269 N 1 3
�Apr� 22 = 97 08 ::54A R . OzOrlc ew'i cz 714 73°1 7338 P.01
B�un �Id�KanSfe me.n-t _
- d a� ty Depart
=This Certificate- issued pursuant to. h0 requirements of Section X 09 of lhe: Unifor n BSwlding Code;
certifying that, at the :time of issuance,. th! 4tructure was in compfiance. with t ipyarious or..dminces 9
of the ,City-regu/ating,.bui/ding construction or use. For the';foffo,wing.-
BUILDING ADDRESS.:. ' 55-575;;,OAK HILL
Use Classification:.' S;FD. Bldg Rermit No.:. 9704'057
Occupancy Group: R 1 Type of Construction: VN .,Land Use Zone: RL:
Owner of Building: RALPH OZORKIEWICZ ' Address: 15370-.BARRANCA PKWY
City: IRVINE, CA, 92713
By: STEVr:.TRAXEL
Date: 3-5-98
Building Official
POST IN A CONSPICUOUS PLACE
f
TM' n
PGA WEST
RESIDENTIAL ASSOCIATION; _INC: ..
June 9, 1997 +;
Marie and Ralph' Ozoikiewicz , }
11912 Skyline Drive,'
Santa Ana, CA 92705
RE: 55-575 Oak Hill
Dear Mr. and Mrs Ozorkiewicz`
The Architectural'.Cominittee,has reviewed yoursplaps for a:custom;home with. pool and spa and
approval is given upon'-receipt of the following itemsN A`.copy ofyour=contractors' current insurance
for both home and pool must'`be filed wittirthe Homeowners' Assocation,office. In addition, the
license .number for California Pools'�is necessary �for;our. files.
We reserve the right to make a `final'inspeetion to make sure the: project' atches the original intent.
Any additional" changes must be made through>�hisoffice with-another request form. All local
building codes, setbacks,; permits and digging-requirements must 'b& met Approval here is based on
the aesthetics of your proposed change only; not `on coni truction worthiness ofstructural integrity.
Please feel free to contact this office. regarding this.' roject s6uld,'yo4' have, 'any�further questions at
this time.
Sincerely
Kel cGallia'd
Operations Manager
c.c. -Don Adolph; Architectural `Comriuttee Chair
Jim Renick CaliforritwPools
P.O. Box 1060,,La Quinta, California 92253, Telephone 619-77,1-1234 FAX 619-771-5125