BLDG (9609-150) + SFD (06265)54555 Avenida Martinez
9609-150
06265
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
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:
(d 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).
( )rl am,exempt under Section , B&P.C. for this reason
Date } 0/-- 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.
(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.
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 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.
I r
;jSlgnature (Owner/Agent) t i*.Date Ili
y
BUILDING PERMIT' PERMTN b °°NTR°96"450412 7
DATE 9123196 VALUATION S3,000-00LOT TRACT
JOB SITE 54-555 t V111 INIJk YINUZ
APN %74-28.5-019 ✓-`p,.'
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
111H, 4'14 8.07.11,' WAGGA)NER%
OWNER/ 110MIX111.111.1
e4 i55 fi VENT.DA 1►1ART1.NF2 -
'
L AQUI:N'fACA 9221 SIA
C:f3f.tf
USE OF PERMIT
GI,)gt:RM, i3i.jtt,.[AW,
12*0 f,lr. 6' 'AfY Nrl) G3A.1tf)rN WALL - f40103 1 tori) Wfs.`xr P/I.
Ra'>; EMA TED CONT OF OONS'i'RUMION
.',41 ti.11a
to14HINIV r VCF,'7e,/M,MARA
Gc.133 TI )itC'.I'lG)N s .!✓f"s !4)1-( {!- },)KW{'!(K) i!)li
SCfE! ' _' . c' . *1 rR 1f_1'10N AN17 PLAN WRECK
$S 9 ()1)
L V, SS P.)<E-PAID 1-1TS
'so.0r,
P.FRAIrT FERE OUF N08
A
RECEIPT
DATE
BY`
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return 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
Pa<ty Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bqpffl 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 Test
Appliances
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
Utility Notice (Perm)
IE
OWNER / BUILDER. INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the. property
improvements specified.
For your protection you should be aware that as "Owner/Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be.licensed.and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-105 Calle Estado
La Quinta,, CA 92253
(619)564-2246
FAX: (619) 564-5617
OWNER'S SIGNATURXADATE
PROPERTY ADDRESS
2�07, /DO
PERMIT NUMBER(s)
CITY OF LA QUINTA
BUILDING AND SAFETY DEPARTMENT
GARDEN WALL STANDARD;
6' C.►1.U.
fm. 1350psi. Fy- 40000psi
f4 O 24' Vert O CL '
/4 0 32' Horiz '
1 •
6 1/4'
v
'ALTERNATE
3' CLEAR T BENDS o
/4 HORIZ. AS SHOWN 1
I { I `1 16" 6- C.Y.U. .
1'-6_• I fm. 1350psi. Fye 40000psi
/4 0 24- Vat O CL
/4 0 32- Moriz
GARDEN WALL
Scale: 3/8' 1•-0'
6' C.M.U.
fm. 1350psi. Fy. 400009si . 3' CLEAR 1
Fp
/4 0 24' Vert 0. CL /4 HORIZ. AS SHOWN 1 T
/4 0'32- Horiz-
OPTIONAL
10-11/16- 130 -LAP GARDEN WALL
Scale: 3/8' 1'-0'
ALTERNATE
3" CLEART N
/4 HORIZ. AS SHOWN I
- 6" C.M.U. '
fT• 1
35opsi. ry. 40000psi
04 O 24' Val 0 CL
/4 O 32' Maiz
1
GARDEN WALL c
Scale•. 3/8' 1'-0' . OPTiONAL
30 LAP
r 6' .C.M.U.
Vm. 1350psi, Fy- 40000psi
/4 O 24' Vert O CL
1. j4 0 32' Horiz S OWN T
/4 MoR,2.
1 - AS SMwN
in
OPTIONAL
10-11/16- 3O'LAP GARDEN WALL
ALTERNATE
3' CLEAR .,BENDS
T
j4 HORIZ. AS SHOWN f ,I
GARDEN WALL
Score: 3/8' 1'-0'
I I T-4bt44Q"
Building
Arfrlrrpc_Q 54-555 ftrti z
Owner
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Address 76-724 Daffodil Drive
City Zip Tel.
Palm Desert 9220 345-1282
Contractor
City
State Lia City
& Classif- I Lic. #
Designer
Address
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 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
hereby affirm that I am exempt from the Contractor's License Law for the following
reasorr (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 appiwnt for such permit to Me 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 the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the appicant to a civilpenalty of not more than five hundred dollars ($500).
❑ 1, 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 of improves thereon and who dues such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
of 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, 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
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.)
❑ 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
❑ 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.)
1 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
Date Owner
NOTICE TO APPLICANT: It, alter makig this Certificate of Exemption you should become
subject to the workers' Compensation provisions of the Labor Code, you must forthwith
comply rdh 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, Civd Code.) .
Lender's Name
Lenders Address
This is abuilding permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 160 days.
I car tity that 1 have read this application and state that the above information is correct.
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
No. 06265
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 774-285-011
Legal Description
Project Description S'
Sq. Ft. Z1
Size
No. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑
Demolition ❑
Estimated Valuation
$92,497
PERMIT
AMOUNT
Plan Chk. Dep.
$250.00
.Plan Chk. Bal.
V 206.36-
Const.
.
,W
Mech.
53-
3w -Electrical
115.99
Plumbing
U-7-50
S.M.I.
6.51
Grading
20.00
Driveway Enc.
20.0
Infrastructure
2,042.93
TOTAL
V3,540.79
his
REMARKS
r.•. . nn •, . n 1-n :rt -s 4 ti;a 5 t1
IfL—z ii,?E#"3 ' ifitiL t
a
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 DATEIy EEC TOR
Issued by: Date—Permit Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES.
IST FL. SO. FT. ® $
UNITS
Oq�LAB GRAD
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
I
2ND FL. SQ. FT.
FORMS
IC TA
ROUGH WIRING
MOBILEHOME SVC.
r
BAR SINK
POR. gp, FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. ®
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
-$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP. zz
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1+/4 c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/4c
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK '�
GROUND PLUMB 1 , (�
UNDERGROUND
A.C. UNIT
COLL. AREA
Oq�LAB GRAD
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
IC TA
ROUGH WIRING
DUCTWORK
ROCK STORAGE
OUND. REINrr.g�--
(
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPIEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
-$
LUMBER GR.
FINAL INSP. zz
FRAMING`�3 4?X A-
FINAL INSP.
OOFING
O /� y.. /- / /J / /�� O, G �)
REMARKS.
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING to141/11 A
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
'
GARDEN WALL FINAL
1
Desert Sands Unified School District
CERTIFICATION OF PAYMENT
OF Ei�efl
SCHOOL FACILITY FEES
TO: City of La Quinta DATE:
Department of Community Development
78-105 Calle Estado
La Quinta, CA 92253 NOTICE: THIS DOCUMENT CANNOT
BE DUPLiCATEDt
This is to certify th t S Dawaw /i�
developer of which is
located at 6 55-10 within
this District, has paid school facility fees imposed pursuant to the
authority generated by Government Code S ction 53080 in the amount of
$ a 6.00 ( i4h g6aod d Iwo
covering a total of square feet of ( ) r sidential or
( ) industrial/commercial development and that building permits for
this footage in this development may now be issued by your jurisdiction.
5D8
for DESERT SANDS•UNIFIED SCHOOL DISTRICT
White - Building Department • Yellow - Facilities Planning • Pink - Accounting • Gold - Developer
(10)-37
Sale
Escrow Instructions
Fran Bridges
Escrow officer
TELECOPIER No. (619) 341.5296
44-900 SAN PABLO AVENUE
PALM DESERT, CA 92260-3537
(619) 568-3627
The undersigned buyers will hand escrow holder on demand
Prior to the close of escrow the sum of $14,000.00 plus
closing costs', $500.00 of which will be deposited into escr
upon signing the within escrow instructions, to complete a
total consideration of $14,000.00, per the following terms:
and will deliver to you any instruments which this escrow requires shall be executed by me, all of which you are
instructed to use provided on or fist. 25th, 1989 you hold a policy of title Insurance
with the usual title company's exceptions, with a liability equal to the total considerations herein covering
10-2908
Escrow Number
_ July 25th, 1989
Date
Paid outside of Escrow
Cash through Escrow
Encumbrances of Record
Encumbrances of Record
New Encumbrances
Total Consideration
Lot 3 in Block 302, Santa Carmelita at Vale La Quinta Unit 28
As per map recorded in book 19Page(s) 59-60 of maps in the office of the County Recorder of Riverside County, Calif.
(Memo: Property Address: . Vacant Lot )
showing title vested in: RICHARD J. SIDDONS . DBA R/S DEVELOPMENT CO. ,
FREE FROM ENCUMBRANCES EXCEPT ONLY THE ITEMS NUMBERED BELOW: ALL A LIEN NOT YET PAYABLE
(1) General and Special taxes for the fiscal year 19_89_, 19 gn , which are not delinquent as of close of escrow
(2) The lien of supplemental taxes, if any, assessed pursuant to Chapter 498, Statutes of 1983, of the State of California
(3) Bonds/Assessments: None
(4) Covenants, conditions, restrictions, reservations, rights, rights of way, easements, and the EXCEPTION OR RESERVATION OF WATER, OIL, GAS,
MINERALS, CARBONS, HYDROCARBONS OR KINDRED SUBSTANCES ON.OR UNDER SAID LAND, now of record, if any.
INSTRUCTIONS:
(A) This sale is subject to buyers approval of the preliminary title report and CC&R'S
within fourteen (14) days from receipt of same, disapproval to be submitted to escrow
holder in writing within said time limit, silence is deemed approval.
(B) Sale is further subject to the conditions required by the City of La Quinta to obtain
a Building permit, approval to be submitted to escrow holder within fourteen.(14)days from
date of applying for said information, disapproval to be submitted -in writing within said
time frame.
(C) Sellers herein is'aware that one of the buyers herein is a California Real Estate
LIscensee and is acting in the capacity of principal herein
(D) There is no broker involved in this transaction and these escrow instructions are the
only.binding contract by adn between the parties herein -and with all signatures hereon
same is hereby approved and all parties acknowledge copy fo said instructions.
All parties' signing this agreement hereby acknowledge receipt of a copy of these instructions.
Prorate taxes based on latest available tax bill as of close of escrow Prorate insurance handed you as of N/A
or buyer will hand you new insurance at his option. Prolate: Homeowner's Association dues as of close of escrow, if applicable
Prorate interest on loans of record as of N/A Prorate rents and adjust deposits as of N/A
based on rent statements handed you. Any rents in arrears are to be disregarded in your prorations.
Credit seller and debit buyer the amount of impounds, if any, as disclosed by beneficiary statements from the holders of the loans of record.
I/We agree to pay escrow fees and charges as charged.
EACH PARTY SIGNING THESE INSTRUCTIONS HAS READ THE ADDITIONAL ESCROW CONDITIONS AND INSTRUCTIONS ON THE REVERSE SIDE HEREOF
AND APPROVES, ACCEPTS AND AGREES TO BE BOUND THEREBY AS THOUGH THE REVERSE SIDE HEREOF APPEARED OVER THEIR SIGNATURES.
RICHARD J. SIDDONS, dba R/S DEVELOPMENT CO_,,
8uy s Signature Buyer's Signature
BY: Richard J. Siddons
Address
Phone
The foregoing terms, provisions, conditions and instructions, and those on the reverse side hereof are hereby approved and accepted in their entirety and concurred in by me.
1 will hand you necessary documents called for on my part to cause title to be shown as above, which you are authorized to deliver when you hold or have caused to be applied
lunds set forth above within the time as above provided. Pay your escrow charges, my recording fees, charges for evidence of title as called for whether or not this escrow is
consummated, except those the buyer agreed to pay. You are hereby authorized to pay bonds, assessments, taxes, and any liens of record, including prepayment penalties,
if any, to show title as called for. Pay Documentary transfer tax on deed as required.
Pay commission as follows $ - NONE to
S
to
Seller's Signature Seller's Signature
JACQUELINE R. GREGORY DAL WOODHOUSE
Address 54-585 Avenita Martinez La Quinta. CA Phone (619) 564-1021
PD 12186
IL
PRELIMINARY CHANGE OF OWNERSHIP REPORT
(To be completed by transferee (buyer) prior to transfer of subject property in accordance with Section
480.3 of the Revenue and Taxation Code.)
THIS REPORT IS NOT A PUBLIC DOCUMENT
SELLER/TRANSFEROR: JACQUELINE R. GREGORY AND DAL WOODHOUSE
BUYER/TRANSFEREE: RICHARD J. SIDDONS, dba R S_DEVELOPMENT CO.,__
ASSESSOR'S PARCEL NUMBER(Sy Lot 3, B1k302, Santa Carmelitaat2Vale La
PROPERTY ADDRESS OR LOCATION. VaCANT Lot
MAIL TAX INFORMATION TO: Name Richard J. Siddons
Address 76-724 Daffodil Drive
Palm Desert, Ca 92260
FOR RECORDER'S USE ONLY
Q inta
A Preliminary Change in Ownership
Report must be filed with each con-
veyance In the County Recorder's of-
fice for the county where the property
is located; this particular form may be
used in all 58 counties of California.
The property which you acquired maybe subject to a supplemental assessment in an amount to be determined by the Riverside County
Assessor. For further information on your supplemental roll obligation, please call Riverside County Assessor at (714) 787.6331.
PART 1:' TRANSFER INFORMATION Please answer all questions
YES NO
❑ ❑ A. Is this transfer solely between husband and wife? (Addition of a spouse, death of a spouse, divorce settlement, etc.)
❑ " `• ❑'" ' B. Is this transaction only a correction of the name(s) of the person(s) holding title to the property? (For example, a name
change upon marriage)
❑ ❑ - C. Is this document recorded to create, terminate, or reconvey a lender's interest in the property?
❑ .. ❑ D. Is this transaction recorded only to create, terminate, or reconvey a security Interest (e.g., cosigner)?
❑ ❑ E. Is this document recorded to substitute a trustee under a deed of trust, mortgage, or other similar document?
❑ ❑ F. - Did this transfer result in the creation of a joint tenancy in which the seller (transferor) remains as one of the joint tenants?
❑ ❑ G. Does this transfer return property to the person who created the joint tenancy (original transferor)?
H. Is this transfer of property:
❑ 1. to a trust for the benefit of the grantor, or grantor's spouse? - - - -
-- - -
❑ ❑ 2. to a trust revocable by the transferor?
,: ❑.::::--: 0:-_-:.: - ::::. 3.-: to a trust from which the property reverts to the grantor within 12 years?.:;..,.:,:::_-:...
O ❑ I. If this property is subject to a lease, Is the remaining lease term 35 years or more including written options?
Please provide any other information that would help the Assessor to understand the nature of the transfer.. .
IF YOU HAVE ANSWERED "YES" TO ANY OF THE ABOVE QUESTIONS, PLEASE SIGN AND DATE ON THE BACK SIDE.
IF YOU HAVE ANSWERED "NO" TO ALL OF THE ABOVE QUESTIONS, PLEASE COMPLETE BALANCE OF THE FORM.
PART II: OTHER TRANSFER INFORMATION
A. Date of transfer if other than recording date
B. Type of transfer. Please check appropriate box.
❑ Purchase 13 Foreclosure' ❑ Gift ❑ Trade or Exchange
❑ Contract of Sale — Date of Contract
❑ Inheritance — Date of Death _ ElOther: Please explain:
O Creation of a Lease; ❑ Assignment of a Lease; ❑ Termination of a Lease
. Date lease began _. _ ..........
Original term in years (including written options)
Remaining term In years (including written options)
C. Was only partial Interest in the property transferred? ❑ Yes ❑ No
If yes, indicate the percentage transferred %
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COACHELLA VALLEY WATER DISTRICT.
CASH RECEIPT DETAIL
Received From: `J�uL-� VPwit�l C_t� )x-82-
0
Date:W-8C7
Address: 7b_7ZL( 7ta(< ON z)0.
cm
Cash
Account No. b� 3 \— io'�. l) b Lot(s) "R
3, D Z Tract
Water Service
Service Address !;'(4 — C �Z Y`n y\r'it Nt�. o
G.A. Code
❑ Meter(s)
$
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❑ Service(s)
Cashier
CVWD-438 (11189)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
Meter Surcharge
(--
\❑
1 Sanitation Capacity Charge \5 S
5 �i 5. 0 0
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water /.Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL $
S 7 S. 6 0
Remarks:
❑Copy to:
Cash
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ca-
f
Water Service
Check
L��K gyp,t.
�r`
Money
Order
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Cashier
CVWD-438 (11189)
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AGIUCUL I UItnI. CU'%"ISSIUI'ILIt
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violation UE yuaralltlne 111.49 kJovemilly 1112 Cvac.lte
do occur Enid they d1E[er [tun 111011t nvllerlai .,sled, tills UEEIce must be IwtiEled
billledlately. .
1'hallk you for lltUlectLly a11d Iltesetvllly llle Coachella Valley's l, est-[ree elrvirolillent.
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cat 11010 and itiverside U[tice
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