9804-090 (SFD)LICENSED CONTRACTOR DECLARATION
,I hereby affirm urider 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
x )I)CU/ 13 I f Y31i99
Date i } � 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
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 forby 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 ry7 Iry y �� IT C Policy No.
ON
(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
subjgct to the workers' compensation provisions of Section 3700 of the Labor
Ce�de, I s�]�all -fohhwith comply with those provisions.
tate:1F Applicant....., t_
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
theaabove- mentioned property for inspection purposes.
Signature (Owner/Agent)"' (. a "�f� ° +� Date
f 1 L
BUILDINGPERMIT PERMIT# ' CONTROL#
�9�i1P�6-913E?
a� pp��
DATE . VALUATION;�8;5,2Ff.(I LOT TRACT f;1pi'
88+1 e ,I a=2
JOB SITE
ADDRESS ���: 16?:"�V' (�1I{ i;1 �Iwi" .IILl�svlb{
APN
77.1+423-0112,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
<"CK (:,1..r1.f:ka c if.:^iTrl;.A1.,
).ACK dCLAXI . GIN13s.i.�1.[..
5,4-330 AVLN[DA HER.RL'KA
54-330 AV1:141DA HElaRI�IRA
LA (jl. INTA (,'A 47257
LA t;NJ191'A CA. 92253
f'C•015ro4_35t 1 CF_tl.,# ; 1, 9
,
USE OF PERMIT
:�1 I
J
.
:. 4 -
bf-u - 1'(s(CA t i L;upS NO t VC,L4AAi 6LC)CfA GdfU_La uit e('�'L. 7y *PLAN �
-'
Ct(N.;h.la+A)UC.1'10N r1PPLIH.D FOR MIYLTIF''LF g1Y1 VI1TVAPAu
MAY
15 1998.
7 KAC'1' C01d X71 UC`i ON 1,503.€ 0 SF
('{l1tC;HJ1'AY'10 77.!10 SIL,'
.
t AKAGE/C;AR1) iRT 448.(4) SF i-1 9®
LAi NTA 1�
6 FT. %V tt'0 I f KIC -2e' 0,00 LFA
ESTI aI%nr'LTED C T Oen CONSTr,
C"0N,TrRUr CI.Ct.td NF>Fc 101-000-4!8-000 $612".%
PLAN CKKIK h_Fy 10.140)439-319 $132.18
NIUCHANIC°AL FEE 101-000•• 121-000 R43.St)
ELECTRICAL r ki Er 1(I -000-420-000 $161. 14
PLUMBINt F FFE 101-000-419-000 5148.9)
`,';T'.1iO1,10 NIOT:ION F0F - RESJ.0 !0.3 Ut}(} ^ai Q!3f) %9.32
f
03RALt'1NC F t? 101-00042.3-000 �4t).aity
INI_-ItA.STItUC:"1'URE f EE '22S-000443-342 �2.U.3+✓,3rt
P.0_08E PIAN 101-000-441-345 S25A W)
FEE f)FP01';,rT 101-00'1-439-318 _S2S0.00
SU R'R-TA 1..(.`1.7wISI tI,!:"1'IC?N A1`1n MAN t.'.1I9'C€i;
: ,fol? 4.4
TOTA], PER MIT FEFS DUE NOW
t
RECEIPT
DATE i
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
�~ OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set, Backs
A
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel,
Roof Dec
_
Return Air
Combustion Air
Exhaust Fans
O.K to Wrap
_ _
I
F.A.U.
Framing
_
/p
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
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
��
Encapsulation
Gas Piping
Gas Testy/
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL#'
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 2_
Utility Notice (Penn)
COMMENTS:
'yai,'aFzF,:.a�:�+sl'4�es-+s.;./+,...-..�„�;d-••�:--w�.,;,...i,_�.. ��'yvyc„
`� � Q ✓VLC
A "A
Building
Ci rS �. �a.bE r✓ � ����
P.O. BOX 1504
A 78-495 CALLE TAMPICO
H
$ I q[j . 06yL<ko), LA QUINTA, CALIFORNIA 92253
Owner `-'
�JAdit Cla.yk fir,
Mailing
Address .��j AJe-r-`k.,YV ewct
City Zip Tel
Contractor
Address
Zip
btateuc. clry
& Classif. So 6b6� ILic. N 11+5
Designer
Address Tel.
City IZip I State
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm th t I am lipensed under provisions of -Chapter 9 (commencing with Section
7000) of Divrt3,�f➢the ugl'n�ar7,Prof+slon_s C, wand my license is in full force and
effect. /�f+LC _ / G/ /7
SIGNATURE t 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 rile 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 thealleged exemption. Any violation of Section .7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars (5500).
C., 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 himselfor through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvemenf 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 1, 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
doesnot 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.)
f] 1 am exempt under Sec. B. 8 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. ❑ 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 (S 100) valuallon
or less.)
I certify that in the performance of ing 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, 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
I hereby 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 for180days. ' -
I certify that 1 have read this application and state that the above information is correct.
1 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,adplicant Date
-Mailing Address
City, State, Zip
WHITE = FINANCE
g584-oQo
APPLICATION ONLY
ILDING: TYPE"CONST. t' OCC. GRP.
'. Number -1 —1'25 131 1:2 1'A /
)al Description t C4 2 bit ZIL .11 * L) 2
Project Description
Sq. Ft. No. r No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation '
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 Setback from Center Line t
Side Setback from Property Line
fy,, 61
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by: P.
Validation:
APR Q 3 1998
YELLOW = APPLICANT
PINK = BUILDING DIVISICJ51 Y OF LA QUINTAO
k
Notice:
.Document Cannot Be'.
e Duplicated
Desert Sands'Unified School. District
82-879 Highway .111
.1ndio,,C-A92201
619-7.75-3500'
CERTIFICATE OF COMPLIANCE
Date 5/0/98 APN #
No. 17016"
Jurisdiction,'' La Quinta
Owner. NameJack. Clark
No. 51-515 Street . Avenida Obregon:
City La Quinta -zip 92253
Tract # Lot # Square Footage
Type of Development Single Family Residence
Comments
773-123-012
Permit #
Log #
Study Area
5•
1,505
4
No. of Units 1
At the present time, the Desert Sand's Unified School District does not collect fees on garages/carports, covered
patios/walkways,.residential'ad'ditions under 500 square. feet, detached accessory structures or replacement mobilehomes.
It has been determined 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
1.93 X L505, : or $`2,904.65 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 Cashier Check/La Jolla Bank/Jack Clark E;e I►one ° 564-3511
p
^t Name on the check -
IT
By Dr. Doris 'Wilson
Superintendent. s'
r Fee collected /exempted by Juanita Green Payment Received f; - e 2 9 4.65
Check No.. 301619
:144
Signature
NOTICE: Pursuant of Assem y 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
above will begin to run from the date on which the buildingor installation ermii for.this ro ect is sssued;or on which the are aidao the: Districts or to another l5ublic entity authorized to
collect them on the District('s)(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
J
RECORDING REQUESTED BY:
OLD REPUBLIC TITLE COMPACOMPANY
98EE.NN7171KC 105791-13 pp qq
WILE AXRST EME�TSD�VOWND'
JACK CLARK, JR.
54-350 AVENIDA HERRERA
LA QUINTA, CALIFORNIA 92253
SPACE ABOVE THIS LINE FOR RECORDER'S USE
GRANT DEED
91-615 AV6 08"caotj
The undersigned grantor(s) declare(s):
Documentary transfer tax is ' 22.00
(XXX) Computed on full value of property conveyed, or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of , and
FOR A VALUABLE CONSIDERATION, receipt of which is ;iereby acknowledged.,
MICHELLE EICHSTEDT, AN UNMARRIED WOMAN
hereby GRANT(S) to
JACK CLARK, JR., A MARRIED MAN AS HIS SOLE AND SEPARATE PROPERTY
L
the real property in the City of LA QUINTA, County of Riverside, State of California,
described as:
LOT 2, BLOCK 2'1, OF SANTA CARMELITA AT VALE LA QUINTA, UNIT 2, AS SHOWN
BY MAP ON FILE IN BOOK 18,PAGES 55 & 56 OF MAPS, RECORDS OF RIVERSIDE COUNTY,
CALIFORNIA
Dated .February 2, 1998
State of California
County of Riverside ) S.S.
On March 26, 1998
before me, Kelly Collier
personally appeared
Michelle Eichstedt
personally knovin to me (or proved to me on
the basis of satisfactory evidence) to be
the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to
me that he/she/they executed the same in
his/her/theiruthorized capacity(ies), and
that by his/her,their signature(s) on the
instrument the esrson(s), or the entity upon
behalf of wh'ch jhe pe (s acted, executed
the instrumeft �: ?�
WITNES�,_my W�q j;no\o4fiki4A Asea
Signatul_�__
MAIL TAX ST
SAME AS ABOVE
AM, -()U-, uhlq"�"
MICHELLE EICHSTEDT
M26F. # 1 �� - 1/',� � CAL OI?� 1xD d; 5 �p � ?, j
(This area for official notarial seal)
KELLY COLLIER
`..�- ..
Comm. #.1057217
-� `'-
. �,;
VUTAP,y PUBW CAltFOR NCA
��' r �G(
T
klYdl'S'A'kl County X
My Comm. Expir8s May, 28.1999 -►
(This area for official notarial seal)
0.6
r -h
CK,
0
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors t
are on this list are the same persons performing the work. Any changes to this list must be approved .
City of La Quinta Department of Building & Safety RCiQC to work being performed by. a changed s
contractor. Failure to comply will result in a stoppage of. work and/or the. voidance of building permi
CITY
SUB -CONTRACTOR'S `' .
TYPE OF
STATE "':` ;: '
WORKER'S
BUSINESS
TRADE
NAME`:.
LICENSE: -
CONTRACTOR'S`:.
'COMP: NAME/
LICENSE
LICENSE ., . ' :..:.':
NUMBER ON FILE
NUMBER/
:
NUMBER .:': `; :.' `; ::
.:
EXP: DATE
GRADE/
A/C -12
61000
STATE Fun►
y 1-]
EXCAVATE:-:
A Fl drCS Ch ✓ i>y
1 3'
I'} -a 3v 13- 9 S
. 9
PIPELINES..
C-34
CONCRETE/
8 oY +� Com.
c -e
3663�5
�
Nw3 a4,6- C
5,
a�
FOUNDATIONS:.
ASPHALT
A
FRAMING
�e C'� u.. vr
C��
B
63'lo44
i-31• o�
STAT FN
-I�t3�i�-`j II -2o -t
`i`185
i z -� - •
STEEL/
C-51
STRUCTURAL.... '
MASONRY
C-29
PLUMBING
Nl. C7A'I v i +l Plumbt rt�
C-36
S15r3y`1.
`s
STATE FW4D
131
e - i
0 0 � • i - 9
LATHING
'C-26
DRYWALL
Q1a13
C-9
1310$0L�
�"
`kA`}
PLASTERING
Cvai �Ukrt-� 1''la,�evi•a.
C-36
6oN4`A
, -
C-1ouDE
14wc,
HVAC
1-:�. 41►1G Ai4,i t, -,t 4(-
'C-20
ELECTRICAL,..
ICwL�'S �G=c-�y��.
C-10-
lGeneral)
? \
v /.
z 9 `I
ROOFING
I?.00�- I �lG Srxc.�K ��
C-39+�.�
e u
SHEET METAL
C-43
FLOORING
C-15
-STATE
Fu►JD
tt1S
GLASS/
C-17
-
GLAZING..''` '>:::."CA{Gi
L'�K:' ✓LlG 1vFt
INSULATION.: '.,
lZvtil�r 1✓16A C,.+ °K.
C-2
3rp1a
Rrfl l ►SEM•
I pay
SEWAGE DISP..
C-42
PAINTING/
�iiwt 4euj-ell
C-33
.DECORATING:,.-
DECORATING:.
TILE :.'
TILE
DI'.� G S��u��►ax
C-54
fap�i�1
5TH +
-I
3 1$
OO1
CABINETS! :..'<::...
hIZ1� C.tMT� ✓t�[-�i�rl
C-6
�L`U%
/ r
INSTALLATION
FENCING..'
6a}L5 Czv--Styuc- I'O'K
C-13
LANDSCAPING
C-27
POOLS
C-53
'
OTHER
Certificate o, -.f Occupancy
J
City of LaQuinta
...
��en anF
This Certificate.. ssued pu'.suant.,to'the requirements of Section .109- of the .Uniform Bui/ding Code, :-
b, -
,cer-if ng ttiat,'at the,-�time•of ssuance, thisstrucfure was in .comp/lance. with:atie various.'ordinances
ofY the City regu.ating bui/ding construct on or, use. For thig-fo/%wing:
BUILD:IRG�ADDR:ESS. :51=5:15 A, EN"I'D`A OBREGO'N
.,Use Classification:,SINGLE' FAMILY' 'DWELLING 'Bldg. Permit No.; 9804=090
Occupancy Group:. 13-3. Type of Construction: VN Land Use Zone: -RC
Owner of Building: JACK" CLARK Address:' 54-350'AVENIDA' HERRERA
Tom„ ra'a..
Building Official
City: LA QUINTA, ;CA:, 92253
By: DANIEL P. CRAWFORD JR.
Date: 9116198
POST IN A CONSPICUOUS PLACE
11