0012-051 (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
Ns?. Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class I Exp. Date
LO
r` 425381 R 07/3112€
c:S� Z r- Date_ Signature of Contractor
(O 0 l h
J U C:) 4,�� OWNER -BUILDER DECLARATION
Huj I hereby affirm under penalty of perjury that I am 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 of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
ce) (=) I am exempt under Section , B&P.C. for this reason
L
N Date Signature of Owner
ON
0)
Q WORKER'S COMPENSATION DECLARATION
It I hereby affirm under penalty of perjury one of the following declarations:
F--' p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W l_ 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 () ( ) I have and will maintain workers' compensation insurance, as required by
U Q Section 3700 of the Labor Code, for the performance of the work for which this
H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
O�;T1�3�i;I1�Y1:f IX3f-a
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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions`.
Dater Applicant h
ZWarning: Failure to secure Workers' Compensat ion.cove'rage is unlawful and
�� shall subject an employer to criminal penaltlesjand 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 Be
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 buildings
construction, and hereby authorize representatives of this City to enter upon
the�above-mentioned property for inspection purposes. ;
Signature (Owner/Agent) - _ Date,! gn 61
BUILDING PERMIT PERMIT#;
+
DATE VALUATION LOTW12_Wf TRACT
gg3` Isks.no 15 14 Il 2{'71ITI I
JOB SITE
APN
ADDRESS
2-37: AVEIa1I1.i A t;1.1: 1: -KC Off
017
OWNER
CONTRACTOR /DESIGNER / EN INFER
1"1,HMIC 11 AM.ES MA':�'�.RiJCIT014
PAC lviC C.R. DES COIN91.R.0C 014
1719
17 ? 910 T' MACIN
S 0MMSIDE, CA' 92054
S 0CM45WE CA 92054
(7CrS,196I-0069 C`.9- Vt 11R55._. ,
USE OF PERMIT
.017 - PERMIT DOES NOT UNCL.UC21s SWCK Wird., PC:OL &SPA OR
D1'R::1V13:WAli'APP13OACH. W. SOUR 'X1.1"PE
TRACT CONSTRUCTION 11332.00 BY
PORCH/PATIO 109'(6 sr
k1ARAt.D1?.� ARPt?1t'i' (S_�) 9;018.W
51x r. WOOD FENCE 20D.06 1,F
EIRE IM) COQ OF C0115117IrsMIC)IR
87,1.9WX)
100N.1Tt?t1O'1'1CO2 a 101.000.4113.000 SS85.�0
PE -AN CHh IK FEAR. 101-01Xt d39-3115
Attie"1•tSA+3 M PEP, 101-000.421a000 SSS.30
fc,UTCTPJC,1311 FRE 101.000-420-000 $106.07
'nx.,UMBI O PER 101.000.419.000 $11Q. i4
.. TitOND NC?TIUN "M - RIMI13 101-000-241-0.00 $8.72
(MADING RF 101.0700-4:23-000 $20.0
r)J,fV1' 0P&PA. IMPACT F10. $1,9 7 Gil
PUICISM PLAN 101-000-441-345 V60.00
.
,
"M D003IT 101.000-439-318 .$250.00
.:13-T"7`A3.:MN:�'RL1t'°itC:l1+f.At3.9.i:►>I.AA1 CH.
$3,380.25
1
:'AIIKYML PElv'.l�i'8 11�"'B?:� DUE NOW
0,130.25
s
RECEIPT
DATE
BY
DAT I ALED
INSPECTOR
4._..I •_l/Uf / 1.
40
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION'
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/
!�,
Underground Ducts [
Forms & FootingsI
O
iL
Ducts [
Slab Grade
fff
Return Air j
:Steel
Combustion Air [
Roof Deck
Exhaust Fans . [
O. K. to Wrap
3= — o (
57
F.A.U. i
Framing `
3 =-�
57
Compressor [
Insulation2
Vents [
Fireplace P.L.
Grills [
Fireplace T.O.
Fans & Controls [
Party Wall Insulation
Condensate Lines [
Party Wall Firewall
[
Exterior Lath
Drywall - Int. Lath
[
I
Final
�Z�DI
57
Final !
•�
POOLS - SPAS
BLOCKWALL APPROVALS
Steel [
Set Backs
Electric Bond j
Footings
Main Drain j
Bond Beam
Approval to Cover [
Equipment Location {
Underground Electric [
Underground Plbg. Test [
Final
Gas Piping [
PLUMBING APPROVALS
Gas Test !
Electric Final j
Waste Lines
_ _ _
Z iG(Bt'
_
S?
Heater Final !
Water Piping
Plumbing Final [
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster !
Sewer Lateral
Sewer Connection
Pool Cover [
Encapsulation i
Gas Piping
Gas Test
111 111
S' fffl o
[
Appliances
j
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
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Z ��
Utility Notice (Perm)
�/ ( B C
57
14
TA,
40imc�
P.O. BOX 1504 .
Building A,, - 78=495 CALLS TAMPICO
Address . ? ?45�,�i/G r%11.� /,L' LA QUINT±, CALIFORNIA 92253 3 7�
......... �.-��✓„+J/,C /c7vS S J mil, �L-t� �=-
Mailing _.
Address 1 '7 /r�
City Zip Tel:
Contractor
ty L Zip Tel..
State Lic. ILlty. N
& Classif. ? Lic.
Arch., Engr.,
Designer
Address Tel. .
City (Zip. (State I
Lic. q
I hereby affirm that,l am licensed under. p wsIons of Chapteg9 (commencing with Section
7000) of Division 3 o he Business and Prof .ions-C/ode�, an�dmyaicense Is In full force�nd
effect. `. _�7 - l 7;;_-, •1 —Q Cr'
I hereby affirm that I am exempt from the Contractoes LI eirise 6w. for the following
reason; (Sec. 7031.5,Buslnsss and-Protessions Cod6 AnY city or, county which requires e
permit to construct, after, improver 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, oadhat. 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 five hundred dollars ($500):
I7 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�oi,fhrough his.own employees;
provided that such' improvements are not intended,or offered lonsale.�ll, however, the building
or improvement is sold within one year of'Complefion, thelowner-biultdar will have the burden,
of proving that he did not build or improve for the purpose of'sale.)
11 I, as owner of the property, am exclusively contracting with licensed coritractors to con-
struct the project. (Sec. 7044. Business and Professions Coder, 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 contrac(or(s) licensed pursuant to the Contractor's License Law.)
f! 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
fl 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 ($100) valuation
or less.).
Icertify that in the performance of thip work for which this permit is issued, l 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
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
ame 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 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' L representat Ives -of this city to enter • the above•
mentioned property for inspection purposes. `
Signalure of applicant Date
Mailing Address
City, State, Zip
0.2 �2 - P25e--/
l
• V
APPL=ICATION ONLY
P��s
BUILDING: TYPE"CONST. - OCC. GRP.
A.P. Number
Legal Description
Project Description f T
;i `
Sq. Ft. ; d NO:, No. Dw.
Size �`� Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
WHITE = FINANCE YELLOW = A
PERMIT
Const.
Mech.
Electrical
Plumbing
S.W.
Grading;,
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
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
Validated by: c+
Validation:
PPLICANT PINK =.BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 2/13/01
Desert Sands Unified School District .
47-950 Dune Palms Road
La Quinta; CA 92253
760471=8515
CERTIFICATE OF COMPLIANCE
No. 21648 Jurisdiction
Owner NameDavid Ross Miller
No. 53-375 Street Avenida:Obregon,
City La Quinta .Zip 92253.
APN# 773-25-4017
La Quinta
Tract # BLK224U21 Lot # 4 Square Footage
Type of Development Single Family Residence
Comments
*Received overpayffi ent, of issue refund.
Permit # 0012-061
Log #
Study,Area
1382
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 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
2.05 X 1,382 or $ 2,833.10. 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 CC - Capital Bank of North County - J.R"RodriguezTelepimar,e 760; 805=_1251
Name -on the check
By Dr. Doris Wilson -
Superintendent
Fee collected /.exempted by Annette Barlow Payment Received $2,846.92
Check No. 080315
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -flay 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 sssued or on which they are paid to the District(s) or to another public 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
01/09/01 10:25 FAX 171608049062
RECORDING REQUESTED BY:,
AND WHEN RECORDED MAIL THIS DEED AND, ,
UNLESS OTHERWISE SHOWN BELOW;'
MAIL TAX STATEMENTS TO:
David Ross -Miller
1719 S. Tremont
.S. Oceanside, CA 90254
S ? -%
SPACE ABOVE THIS LINE FOR RECORDER'S 115E
The undersigned grantor(s) declare(s): G.1'ar111t: Deed
Documentary transfer tax is $ "
( Xw) computed on full value of property conveyed, or
( )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;.
ROBERT F.•& ELISE J. EBBERT
hereby GRANT(S) to DAVID ROSS :MILLER, a marraed man a's his 'sole and. separate property
the real property in the City of La Quinta County of :Riverside
Stale of California, described as
F
;Lot 6==N of Brock_: 1 1 bnit` No, ";Santa 'Carmelite at Vale La Quints,
as per map recorded in. Book 46 pages 18mf Maps,' Records .of Riverside County,
California
Dated January 19, 2001
,Signature of Grantor
State of California )
Countylof
On before me,
Robeft. -F . Ebbert
,personally appeared
Elise J: Ebbert
personally known to me (or proved to me on the basis of satisfactory —• •• —
evidence) to be the persori(s) whose name(s) is/are subscribed .4o.Ihe
within instrument and acknowledged to me that he/sheAhey executed-
the
xecutedthe same in his/her/(heir 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, �.. e_ a 5 aBa:ra
Form 3195-4 (6-94) I' THIS FORM FURNISHED 13Y COMMONWEALTH LAND TITLE COMPANY
RC _DISTRICT _:PLANNING REVIEW FORM
This form is to be used by. GDD.staff for,review of.single family:dwellings in the RC (Cove Residential)
District, in order to determine, -the applicability of compatibility issues or need,:to require the filing of Master
Design Guidelines by. the applicant It shall be transmitted to ,the Building and Safety Department as your
correction list.. Please attach additional explanations as necessary.
APPLICANT PACIFIC TRADES
SITE ADDRESS. 53-325 Avenida Vallejo /V0 4sC + %s wEN -bA-
APN-- - BINNO.:- `� �/ CASE NO.: 20.00-371
LEGAL: LOT BLOCK UNIT / S.C.@V.L.Q.
CHECKED BY: Stang Sawa DATE: ZO 100
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/CORRE"CTION
Compatibility Review
Case logged and number assigned
V
Verify legal and APN, information
V
Consistent with MDG on file (as.applicable
MDG filing required (5 -filings since 9/3'/98)
Consistency with street/surrounding area:
Colors
Materials
Architecture .
Other Requirements:
,rr
SAq