0204-123 (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
Dafe' n c Signature of Contractor. E a
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that l 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 propeity, 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 for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
,Q'I 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 STATE rUm Policy No. 15 7TI-9 5
(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.
Applicant c' J-
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in`Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his ..
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
.� k.
Signature (Owner/Agent�l Date
. ,;..BUILDING PERMIT PERMIT
DATE /` 07VALUATIONS LOT TRACT ELY;
vi
JOB SITE APN
ADDRESS 52.175 AVEN'IDA O.Jd=;0N 74,21446
OWNER
JAW'S BRUNAP
POt3k.OX 237
PALM, DESERT CAA. 0.2261
CONTRACTOR/DESIGNER/
USE OF PERMIT
S1T.0 n RIS r DONS N(MNCLI M1. H1ZKXWALL, 'Kt.'� : 0P,. I)PJVRWAY
A h`'ROA . W 3i3£Ct:",V 160 S.F. MASTER N75%1.°% AN MCK,
TRACT WNSIRU(NION 104-00 sre
iAOTtL:I'raf>Q.H: n0 I11.00 W
GARACa` LANK U 420.(* 10
i PT, XV001 130.W TF
.. xs�.ni'•°.i���i�, 4.�1ki�irl�,3.�L'°:6'!�?.N e'.,t}ti�� r�,.�,rr C�.P
I'M, MRNITF7,X3 D11K, NOW
U APR 2 3 2002
CITYOFLAQUIWA ,
FIR MCEDEPL
RECEIPT DATE r = BY ` s DA -LE FINALED INSPECTOR
jp� (�� � pq �y�� � �*y,}y p�/�y��g4. ((� y ��r �{t p•�,q �
&IIIA.h.P# T4 91) LKM, 6J 1 Y.A )N- III"- 4 S:8V.I4.�R. OIN
5 ](�iQp7� / 9V{� �n � �1'�''(��N� q ,p ffi14
.YSU.$AST'!7{R. S ,1C�1N�G i. V'S�If.7P$S`illfiRIV
CONS'MtI"111014T M"
101-0004M000 000
30.50
PLAN f` MCKM '
101 -M -439-31R,
$131-35
M.'GEN 'dE
101-00-439-318
4250.00
5=41CAI YVE
101-L)W420-000
$11104
F%I.910M. i FFIV
1.01•d 419- fk
4s .tb6.is
WV=40 M iJ14 Mi-1"ZESZ)
101-000-241-M)
. a9
e 4ia'.l1`I FX9i.66.fd(HI€)-41
6430
+ 1.
1'R.WU PLAN
1014X'0-441-;343
$300.4
.. xs�.ni'•°.i���i�, 4.�1ki�irl�,3.�L'°:6'!�?.N e'.,t}ti�� r�,.�,rr C�.P
I'M, MRNITF7,X3 D11K, NOW
U APR 2 3 2002
CITYOFLAQUIWA ,
FIR MCEDEPL
RECEIPT DATE r = BY ` s DA -LE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs::fx
of
Underground Ducts
Forms & Footings
O Ci
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
• o Z
Exhaust Fans
O.K. to Wrap
e--
F.A.U.
Framing
Z
Compressor
Insulation
L
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. ! . o i
Drywall - Int. Lath
Final
Final ' v
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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
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
- f%Y
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole ®t/
Underground Conduit
Rough Wiring
Lang Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) E p Z
COMMENTS:
�yTT�'�'-�Srr //�/�; �`�"[i?+i��►,e7`,-KF�!#'�i('�. •Y'��'�.+�' ' Ti.�'y��� p.. ;...,saragL-,r�•��1'�-���p.�s�.-';°"V+""' a "'F
tlGl�tr
D oY46U
P.O. BOX 1504
�} ff�1, 78-495 CALLE TAMPICO APPLICATION ONLY
Building � �d �./Ir.+� : P',t
Address +.Jct' ✓LA,QUINTA, CALIFORNIA 92253
Mailing V
Address
��
City
Zip
Contractor
Stories
AOOress ^^��
City, zip
State LIC.
& Classif.
Arch., Engr., r.
Designer j
_ BUILDING: TYPE'CONST.� OCC. GRP.
A.P. Number
Legal Description
Pro'ect Description 1
J
City
Lic.k���>r^
Address ]J ( Tel,/,_
City -Zip State ~���
�.lJ, �tL r� �f�c Lic.fin�./U�
' *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, 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 thathe 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).
I] 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 suchimprovementsare 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 proiect. (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 1 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
r'] 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 it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of 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, 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 it work thereunder is suspended for 180 days.
I certify that I have read this application and state 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
I
/ rlA
Size t 16 Ur y
Stories
Units
New ❑ Add ❑
Alter ❑
Repair ❑
Demolition ❑
Estimated Valuation
PERMIT
AMOUNTr
Plan Chk. Dep.
-19
��` S '
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc
Infrastructur
F
fr
TOTAL
t
REMARKS
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
Issued by: Date Permit
Validated by:
Validation:
YELLOW = APPLICANT
PINK = BUILDING DIVISION
Desert Sands:,Vnified SchoohDistrict '
• 47=95.0 Dune -Palms Road' "•
Notice:
. •La Quinta,.CA 92253
Document Cannot Be Duplicated 760-7718515;
CERTIFICATE OF COMPLIANCE
Date 4/23/02 APN# 773-181-022;
No. 23'156 Jurisdiction, "La Quinta
Owner,NameJames-Belknap " Permit # 0204-121
No, 51-955street Avenida Mendoza Log #
City La Quinta Zip 92253 Study Area
Tract # BLK118U12 , Lot # 1.0 . SIll uare`,Footage. "1604
Type of Development ,1 Single Family Residence No. of Units -1
Comments'. ,
At the present .time, the Desert Sands Unified School Distnct •does -.not collect fees -on garages/carports, covered
patios/walkways, residential additions ,under 500 'square. feet; detached' acc'ess`ory. structures or'replacement mobilehomes. It
has been determinedthe 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
2.14 X 1,604 or'$ "3,432 56>. the property listed above arid that building
t ` _ .g•
permits and%r Certificates of 0ccupancy-for this square footage m diA proposed.project may now be issued
Fees Paid,By CC/Guaranty,'Bank -=:James. C. Belknap, Jr., Telephone 777-9572
Name on.the check `+
By Dr:, Doris. Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $3,432.56
Check No. 2111105 _
Signature •
NOTICE: Pursuant to' sembly Bdl 3081 (CHAP 549 STATS."1996) this wdl serve.to notify you that the•90-day approval penod ih,which you+may protest the fees or other payment identified
above will .begin to i om the'date on which the bmlding'or installation permit for this project is sssued or'on which they are paid to the Districts) orto another public entity authorized to
i collect them owthe D : ct('s)(s );behalf, whicheveris earlier. •� • -
Collector: Attach acopy of county or city plan check application form,to district, copy for all waivers.
Embossed Original- Building Dep /Applicant Copy - ApplicantO ceipt Copy - Accounting
_ w
RECORDING REQUESTED BYE
American Title Company
AND WHEN, RECORDED MAIL TO:
James C. Belknap; Jr.
32 Camino Arroyo Place
Palm Desert, CA 92261
7 02 —. 'i �' _ O At G71
Space Above This Line for,Recorder's Use Only
A.P'N.: 773-214-019!A TRA #i: b20=017 Order No .:27055124 .' - • Escrow No.: 02 -2307 -KY
GRANT DEED
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER"TAX IS COUNTY 38.50
X ] computedion;full value of,:prop'ertysconveyed, or`
computed on full'value less.value of liens or encumbrances remaining at�time of sale,'
unincorporated• afea- [ X .] , City of La• uinta , :and -
-
FOR A VALUABLE CONSIDERATION,;.Receipt of which is hereby acknowledged,
William R. Riley, Trustee of .THe William R..' -Riley -499,4. Trust
hereby GRANTS) to James C;,_Belknap, Jr. Trustee of. The James Belknap Separate : Trust dated May 5, 1992.
the following described`property in'the City of .La Quinta, County:of Riverside State of California;
Lot 8, in Block 2, of Unit 1, of Santa Caimelita at VakLa Quinta, in the -City ofl;a",Quinta, County of Riverside, State of
California, as per_map recorded -in Book -18, Pages) 466 Maps,.in 'the Office `of the ;County Recorder of said County.
William R. Riley, Trustee of The
Willi R. Riley 1994 Trust ,
By
William R. -Riley, .Trustee
Document Date: March:5. 2002
STATE OF CALIF Q]2 i1A . )SS
COUNTY OF /� i 11e -
On
R S� De
before me �!i-� 1 r
personally appeared
personally known to me (or proved to meson the basis of satisfacto ,evidence)'to be theperson(sj whose.name(s);is%aresubscribed to ithe within instrument
and acknowledged to me ttiat he/ske[tbey'.executed�,the same m his/hg&'Ahei'rauthori ed'eapacity(ie's):and, that.tiy his/t eNtlwir signature(s) on the instrument
the person(s) or the entityupon behalf of which the'per§oi►(s) acted„executed the tnstiuin
WITNESS my handand *official seal.
Signature'•J'
KATNRYNwM YASI This area for official notarial seal.
V COMM::A 1221410
(7 i�
1 � NOTARY PUBLIC CAUFORNNW
°RIVERSIDE COUNTY '�;pA COMM ,EXP MAY 25, 2005{
Mail Tax: Statements to:--• SAME AS.-ABOVE.;or Address Noted Below
R.G DISTRICT - PLANNING".REVIEW FOR -M
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 200 feet of=the applicant, and/or 2) if there is a need fob the applicant to file for
Master Design Guidelines.. If the.applicart does-need.tofile 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 Belkna
SITE ADDRESS
A P N 773.`= 21,4`: ;0.19':. CASENO.: 2002-639
LEGAL: LOT 8 BLOCK"' 2 UNIT S.C.@.V.L.Q.
CHECK AND APPROVED BY: Martin Manana DATE:
Inform the assigned Building. plan. checker -upon 'your :assignment .to this. case. The CDD
Executive Secretary maintains a log book to tr-apk :applications and assign case numbers.
REQUIRED ITEM
Y'
N =.
COMMENT/CORRECTION
Verify legal and APN information
Consistent with Mb.G'.on file (as
applicable
MDG filing required (5 filings since
9/3/98) _
CITY OF €._A Cit QINTA
Architectural variety within 200 feet of
PR o 2 RECD
the surrounding area:�AFE
Colors
Materials.
Architectural design featuresQ
r
wed b . . BM 9A
ening Commission
PI
Other Requirements:
r
C
Initial
`ounci
mmu it . Dev. Dept. Ot
-
,->206
Case
No;..' •. , 2..fp�
.._._ _.
xhibit
Wil
h1Gonditione- r
Certificate of Occupancy
City,of La Ovin -ta
Building and Safety Depart-m.ent
This -Certificate issued pursuant to- the requirements of Section 109 of the. Uniform. Building,_ Code,
certifyi ngjhat, at_the time of issuance; this structure;. was in,comp/ance. with the various ordinances
of the City regulating building construction or :use. -.,For the '&116wing:
BUILDING ADDRESS: 52-175 AVENIDA OBRE,GON
Use. Classification: SFD Bldg. Permit,No.: 0204-1;23
Occupancy Group: R3 Type of Construction: VN Land Use -Zone: RC
Owner of Building: JAMES C BELKNAP JR. Address: 73-300 FIDDLENECK.,
City: PALM DESERT. CA 92261
By: KIRK KIRKLAND
Building Official
Date: 8-13-02
POST IN A CONSPICUOUS PLACE