SFD (0109-001)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 m' License is in full force and effect. `
Licrnse # Lic. Class Exp. Date
h
1381 In(
Egate " ?1'' +�;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 contractingwith licensed
contractors to construct the project (Sec. 7044,. Business 8,vProfessionals
Code). i
( ) I am exempt under Section , B&P.C. for this reasV,
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-insuf,� for workers'
abo
M
compensation, as provided for by Section 3700 of the Lode, for the
performance of the work for which this permit is issued. /Z
I have and will maintain workers' compensation insurance, as required by
Sdbtion 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. "
VIVATiv
(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' compensation4proV.isions of Section 3700 of the Labor
God , I shall forthwith comply with those provisions. e
Date: �Applicantt
Warning: Failure to secure Workers' Compens tion coverage)is unlawful and
shall subject ani employer to criminal pen Itiesd civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor. Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to'
any permit issued as a result of this application agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void,if
work is not_ commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
ti
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and `State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above mentioned pngperk for Inspection purposes
S'h ature (OwnedAgent)`^
BUILDING PERMIT PERMT#
DATE / VALUATION LOT s' iaC9-j (
TRACT
NILK 146
JOB SITU / 1
APN
ADDRESS y� 99 �dry�s,+��
Ry,{
71".
.'1'.�.��'l Z3
r •AEF'-.. cNo7 d']. ,J:��.69b.dI'lf�..6!"f.'fC•. FJ"l.Z".GwO
(F
OWNER k
CONTRACTOR / DESIGNER / EN INEER
I`,
3A�il a��'.;.�t i..
P.A4.5M0 TRAM t tdRSTR'i5t°:"'1:.10N
aA,
S C9CLI;A4I';�mi
CA 942054
C9
CM -0. 1955
PSE OF PERMIT
to
SI1. PERMI X)VIS X11110M 13UXK'W ?,� P0011 OW'DRAV811.
A,.IaHK)ACK 48' �ii.�.S'3 FfK ,"10AN FEL('P.F;" C,7D
Lr\ a
p�20bu)
alaS".00
TRACT OUNSTRUC:TION "1460.00
S.Y CI ( OFLAQUINTA
O.f�tl.r'�I'3EIC.�►RF�i�RT S
F NANCE DEPT.
5 Fr. 'BOOP VIEWfu , 200.0 ;f„ It'
XTIMA'1' D C'd.3Y' OF CO.I!$MCY.r.TNON
PERNTfT YET MUMMY
CMCSTRUC TION WE 101-000-418-000
P1,,e4N CH CK FEE 1fel•CkOt�-439"SflF§ �9�8,"i6
MEClaAMCAL YER 101-000-421-000 X35, Qin
FA. i RZl# .e L FPJ..: 101-00.4210-000 f Ot9.07
1•''LUMB1140 F -Y- C 101-000,011 9.001D
STRONO fhT4! ION ME 92SS1.0 101-000-241-000 W72
�1�:t�1k�C13 101 "Ci00a4�;�<Ez� 5�tls.ttt3
0.lyV:'&W1'_RR f.h§p«' cll F—O.U.
V
MCIR1"�a�?! 3J'1 MGCfO��l4? a;4�i.3 �EGO,(ItR
SM-TMAJ- t°. C'PI+ISMUC' ITCON Aks',M PLAN CW
`3,380.2$
JIMS PRE -PAW PER* .$250.00
"Aym T'' WT 1~IfIX"S DUE NOW
k4e� 3
RECEIPTDATE
BY'
LE D T FI
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
/_ _
�/ �?�c�%
F.A.U.
Framing.
Compressor
Insulation
L��
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
!_ �(J !Z G(
POOLS - SPAS
BLOCKWALL APPROVALS
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
%_ Q s`�
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
f% 5
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
py
Utility Notice (Perm)
P.O. BOX 1504 APPLICATION ONLY
Building78-495 CALLE TAMPICO
Address I-• 4 Ayl// �' "' LA QUINTA, CALIFORNIA 92253
Owner
Mailing
Address/
City I Zip Tel.
contractor
Aaaress I
ip
State Lic.� City
& Classif. ,/ �% Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirrtrtrt° that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of tip Z, of the Business and Professions Code, and my license is in full force and
effect. 1x
SIGNATURE A \ e / .1 •-1 DATE
UIL
^.\ OWNER-BDER 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, alter, 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 0! the Business and Professions Code, or that -he is exempt therefrom, and the basis
!or 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).
l: 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 such improvements are 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 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.)
I I 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
177 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.)
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.
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 representatives •of this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 7% 3 } �'
Legal Description�1
Project Description
S Ft /
Stories Units
New 0� Add ❑ Alter ❑ Repair ❑ Demolition ❑
r
i I1
t
>timated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
15 4 .,
TOTAL
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
Issued by:_
Validated by:
Validation:
CITY OF LA QUINTA
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
r Desert Sands'Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253 =
Document Cannot Be Duplicated 760-771-8515 i
CERTIFICATE OF COMPLIANCE
Date 9/24/01
No. 22525
Owner NameDavid Miller
No. 52-935
Street Avenida Mendoza
` APN # 773-332-023
Jurisdiction La Quinta
Permit # 0109-001
Log #
City La Quinta zip 92253 Study Area
Tract # BLK 146 Lot # 10 Square Footage 1382
Type of Development Single Family Residence No. of Units 1'
Comments
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
4
This certifies that school facility fees unposed 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 / Mission Oaks -National Bank - J.R. Rodriguez' Telephone 760-967-0069
' Name on the check'
By Dr. Doris Wilson ►k
Superintendent
Fee collected /exemp d by Annette Barlow Payment Received $2,833.10
Check No. 10845 .
Signature 1r
OTICE: Pursuant of Assembly 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
)ove 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 Distict(s) or to another public entity authorized to
Aect 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 I Copy - Accounting
01/12/01 ':14:30 FAX 17608x'49062 COMMONWEALTH "-,TITLE 01001
RECORDING REQUESTED BY:
a ,
■ 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
r -
SPACE ABOVE THIS LINE FOR RECORDER'S USE
The undersigned grantor(s):Grant Deed A.P.N. 773-332-023
declace(s): -
Documentary transfer tax is $
( ;;x) computed on full value of property conveyed, or
( ) computed on full valueless value of liens and encumbrances remaining at time of sale.
( ) Unincorporated area. ( ) City of and'
FOR A VALUABLE CONSIDERAT!ON, receipt of which is. hereby acknowledged,
RICHARD & ALICE MERTZ
hereby GRANT(S) to DAVID ROSS MILLER, a married man as his 'sole and separate property
the real property in the City of La Quinca County Of Riverside
State of California, described as ,
Y
Lot 10 of Block 146 Unit No, Santa Carmelita at Vale La Quinta,
as per map recorded iu Book Pages 6f Maps, Records of Riverside County,
California
Dated August , 1 3 , 2001 Signature of Grantor
- Y
Stale of California )
County or -
ALICE & RICHARD MERTZ
On before me,
,personally appeared
Richard .& Alice Mertz
personally known to me (or proved to me on the basis of satisfactory --
evidence) to be the person(s) whose names) is/are subscribed to the
within instrument and acknowledged to me that he/she/they executed
the same 'in his/her/their authorized. capacily(ies), and that by
hls/her/their signature(g) 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 r
MAIL TAX STATEMENTS TO, eases a,s abev�
dorm 3195-4 (6-94) i THIS FORM FURNISHED BY COMMONWEALTH LAND TITLE COMPANY
p
City of La Quinta
Building and Safety Department G�°v
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure. was in compliance with the various ordinances
of the City regulating building construction or. use. For the following:
BUILDING ADDRESS: 52=935 AVENIDA MENDOZA
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0109-001
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: DAVID MILLER
00,
Building Official
Address:
1719 S. TREMONT
City:
OCEANSIDE, CA 92054
By:
RICHARD KIRKLAND
Date:
MARCH 6. 2002
POST IN A CONSPICUOUS PLACE
I