0104-049 (POOL)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
96565 T? 10/"31/2f
ate 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 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 Policy No.
STA'V'E FITHD 1242713.99
(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
ubject to the workers' compensation provisions of Section 3700 of the Labor
Code, 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.
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 130 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
billtstruction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 010,4-049 TRACT
04M12 0.0 1100)0 16 kti .25334
JOB SITE
APN
ADDRESS
54- lee AVENIDA AL ARADO
774-203-009
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DOJ3AL) TERRY HAMILTON
EAti ryVALLEY CON I1 * CIO
PO BOX 1281
543:,0 AVE. ALVARA O
LA, QU1NT.A. CA .92233
L..A (PINTA . CA 92253
(76O)564.4Y44 CBLif 1961.
USE OF PERMIT
POOL) D/OR f. TA
POOL :`>y P1 ONLY. ALARMS/BARRIESS SHALL DE Trig PLACE AT PRE
PIASTER THSPECTION.EQUIPMF,14 FAC.LOSUR' NOT INCLUDE ro THIS
PERMIT
VALUATION 1 ti„ 0D0.ODl .L
i',I9'Im5 T11.'3`!D con ' Uig' CONSTRUCTION ION
1I),[it 2.00
P.a vrae, sUIVIMAY
3'1M CHECK PM 101.000439 -316 $76,05
O ST UC"i, SO FEE 101 -•0O0 -4I8 -0o0' SI 17.00
ECitf4liMAL FET. -• pool, 101-000-421-000 $24.410
ELECTRICAL FEE'„n POOL, 101..000-420-000 td)
PLUMBING 61 -- POOL 101-000.419.000 S? too
•lCil6 �p0 LY! P 'PATD FEESx{1,00
PQFs DOE NOW
(2.1.5
c\r of
Ott11E111 11\r �
RECEIPT
DA��TjE/ /
BY
DA/TSE FI LE%� orcl rOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECT Q
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.Grills
Fireplace T.O.-
Fans & Controls
Party Wall Insulation
Condensate Lines
Party'Wall Firewall '
Exterior Lath
'
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
/f
Set Backs
Electric Bond
D
t _ t r/_�(S
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
4(($ (ci
11
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 Test
Appliances
/� /
(� 6/ D f!—,5�
c
Final
� alei 57
COMMENTS:
k iuee � /,4--"i),
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
Utility Notice (Perm)
Recording Requested By
74ECAUTIEICATEWPmPanY.
Fidelity Netional Title Company
Escrow No. 41790 -CB
Title Order No. 2172768
When Recorded Mail Document
and Tax Statement To:
Mr. and Mrs. Donald Hamilton
P.O. Box 1281
La Quinta, CA 92253
1111 II IIIII III IHH II 12
IE
The undersigned grantor(s) declare(s)
Documentary transfer tax is $44.00
1 X 1. computed on full value .of property conveyed, or
1 1 computed on full valuelessvalue of liens or encumbrances remaining at time of sale,
[ 1 Unincorporated Area )(City of La Quinta
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
and Linda Page
G. J.
hereby GRANT(S) to Donald Hamilton and Terry Hamilton, Husband and Wife as Joint Tenants
®OC et 2®®®-317126
08/13/2000 08:00A Fee;12,00
Page 1 of 3 Doc T Tax Paid
Recorded in Official Records
County of Riverside
Gary L. Oreo
Assessor, County Clerk a Recorder
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EXAM
GRANT DEED
S'-1 - O .
nv-c r+vvvc Irmo -Lama rvn -rrca.vnucn
Victor Lysiansky,
AM
the following described real property in the City of La Quints
County of Riverside, State of California:
Lots 15 and 16, Block 253, of Santa Carmelite at Vale La Quinta, Unit #24, as per map recorded in Book 19, Pages
44 and 46 of Maps, in the Office of the County Recorder of said County.
DATED: August 3, 2000
ST OF CALIFORNIA
COUN OF
ON 7 before me, Victortysiansky
- personally appeared
�`. p�S�wCM �•
� 6
personally known to me
of satisfactory evidence)
namets) is/are subscribed to t
acknowledged to me that he/s
same in his/her/their authorized ca
by his/her/their signature(s) on th
person(s), or the entity upon behal
person(s) acted, executed the instrumen
r proved to me on the basis
be the person(s) whose
within instrument and
/they executed the
city(ies), and that
instrument the
f which the
Witness my hand and official seal.
Signature
' MCkhI
Linda Page
MAIL TAX STATEMENTS AS DIRECTED ABOVE
FD -213 (Rev 7/96)
GRANT DEED
w
ter. aALIFORNIA ALL•PURPOSE ACKNOWLEDGMENT ..:Ili dl I .f;.'
���J./.�ll_C_.�!!✓!.!3"�JlJ1..�-/!�/!1.1.1.Y.i�`J"�l././ltd./l../Jl�Yl../.1.i",/l.,/1-/-/,/:/`,/!�1!1Jll✓1,�1l�`
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State of (RI rnt (,
County of krttAr e,
On Q _-- a 1) SOV) before me, Susan T. Kaminsky, notary public,
ATE �1 L NAME, TITLC OF OFFICER •E.G.,'JANE DOE, NOTARY PUBLICpersonally appeared L_i&xt e�- &-b11 o.i tuN Ctttorner'n
G OF NER S)
*0'{ �l ,►r' gal (('
OR - �•1 proved me�oh the basis of satisfactory evidence
to be the person j whose name,01) Dam
subscribed to the within instrument and ac-
knowledged to me that We/ tAty executed
the same in Ks/Cyt. it authorizedcapacity(i4), and that by its/er/their
signature(* on the instrument the person,
or the entity upon behalf of which the
person.( acted, executed the instrument.
SUSAN T. KAMINSKY
Commis,lon #1150039 1'
Notary Public - California
Orange County
My Comm. Expires Aug 4, 2001
WITNESS my hand and official seal.
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0
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OPTIONAL
SIGNATURE OF NOTARY
Though the data below is not required by law, it may prove valuable to persons relying on the document and could prevent
fraudulent reattachment of this form.
a
CAPACITY CLAIMED BY SIGNER DESCRIPTION OF-ATFAC-HED DOCUMENT-_ ..--
❑ INDIVIDUAL
0 CORPORATE OFFICER
❑ PARTNER(S)
TITLE(S)
0 LIMITED
❑ GENERAL
ATTORNEY-IN-FACT
❑ TRUSTEE(S)
❑ GUARDIAN/CONSERVATOR
❑ OTHER:
SIGNER IS REPRESENTING:
NAME OF PERSON(S) OR ENTITY(IES)
&rcir-A' V2324
TITLE OR TYPE OF DOCUMENT
NUMBER OF PAGES
DATE OF DOCUMENT
LtAdG1/4) e()
SIGNERS) OTHER THA NAMED ABOVE
s
1
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01993 NATIONAL NOTARY ASSOCIATION • 8236 Remmet Ave., P.O. Box 7184 *Canoga Park, CA 91309-7184
RECORDING' REQUESTED BY:
Fidelity National Title Company
Escrow No. 41796 -CB
Title Order No. 2172768
When Recorded Mail Document
and Tax Statement To:
Mr. and Mrs. Donald Hamilton
P.O. Box 1281
La Quinta, CA 92253
N: 77-4-203-009-2 and 774-203-010-2 GRANT DEED SPACE ABOVE THIS LINE FOR RECORDER'S USE
The undersigned grento.r(S) declare(s)
Documentary transfer tax is $44.00
( X I computed on full value of property conveyed, or
( 1 computed on full value Tess value of liens or encumbrances remaining at time of sale,
[... ) UnincorporatedAreaCity of La Quinta
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, Victor Lysiansky, To Be
Determined and Linda Page, To Be Determined .. .
G. J.
hereby GRANT(S) to Donald Hamilton and Terry Hamilton, Husband and Wife as Joint -Tenants
the following described real property in the City of La Quinta
County of Riverside, State of California:
Lots 15 and 16, Block 253, of Santa Carmelite at Vale La Quinta, Unit #24, as per map recorded in Book 19, Pages
44 and 45 of Maps, in the Office of the County Recorder of said County.
DATED: August 3, 2000
STATE OF CALIFORNIA
COUNTY
r ... . '- .– . before me,
04)7.5 v,/- , personally appeared
e . L A-4)4 r4 c P
personally known to me (or proved to me on the basis
of satisf tory evidence) to be the persons) whose
names)/are subscribed to the ithin instrument and
acknowledge. to me that he sh they executed the
same in trtheir authorize capacity(ies), and that
by his/ : heir signature(s) on the instrument the
person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument.
Witness my hay offici
Signature
Jt�ne�i r, c.00t.it-e,rPwr�
JAMES T. DUNCAN 1
COMM. #1249336 1
NOTARY PUBLIC • CALIFORNIA tj
ORANGE COUNTY CO
MY Comm. E�gsires fab. 9, 2004
MAIL TAX STATEMENTS AS DIRECTED ABOVE
FD -213 (Rev 7/96)
Illffl IIlIIIffl 1111111111011110111101 IlIlilIO101
2M-317126
98/15/2999 08 68R
3 of 3