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SFD (0104-089)t LICENSED CONTRACTOR DECLARATION herEby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businessland Professionals Code, and my License is in full=force and effect.. - License # Lic. Class • Exp. Date Date'.,,' 'Signature of Contractor q. ' OWNER -BUILDER DECLARATION t ^� I hereby affirm under penalty of perjury that I am exempt from the Contractor's r, 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. ("0 1 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. ITAT MD l ��E;s49I:-OS (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 witl4aliose provis on's. Date:,14— a/_ Z / Applicant —Wa' rfing: Failure to secure Workers' Compensation,.coverageN's unlawful and shall subject an -employer to criminal penalties and ci I'f nes up o $100,000, in addition'to,the cost of compensation, damages as provided for i 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. ;h• 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. Signature (Owner/Agent) } ` `� �, � Date '5 °" J i BUILDING PERMIT PERMIT# A, DATE` t / VALUATION LOT 01,044DB9 TRACT • . 4 J lit: ` CY JOB SITE APN ADDRESS x 7'S AVEMDA. WX"1 O&% 174-W.2-021 OWNER CONTRACTOR / DESIGNER I ENGINEER J.��,�Y .li�'.L�.'.J�07 YiJd.➢..t. CrZ�. �d'�iSwA➢.'Li✓ t�197.J'dSyR•i \n...l:A`2J J.11.1J1g63.�.C� 1739 t43 iR.��ti01 T LA QX;JN7A OA 92253 VOCIEM19,L0T~ CAo, 92054 (16P)967-0069 1".13 .11 1955 USE OF PERMIT. E290 DVEaly VD -PERMIT 4OIF-Na yyrtLCD ih%K Vp LI, DygytYAPVioAC-1i ✓ R POOL MASTER B-1 TRACT CONS'fk UCTIOX Sly Int" RCaIIII)ATIO 0U.00 F 5 FT, WOM PKI40? aoL' 11111.1r •.:..... p �1 X633; 463.00 SAP ESTIMATED [:06'7' 01P Ci:D:r+ MRVC ION 92"IA0 'RIM" Y SWUMARY FTS DEPOUIT 101 -000-4394 .418 -3250.00 00HS T'RT1CTION F',KF. 1101-000418-M, p9f1 to PLAN C.'r3:ECK FEW 101-000-439-316 S36$15.2 N.RCHANICAL FER 10 1-004 421-00 ' $53.50 EL1-'1'HICAL .. r 101 -WO -420-000 V30.1" Pi.[ MSz1INO FEE 101-000-4)9-000 %W.73 S "12..C?HO MOTION F0,, - USID 101-000-141-000 �91II4 OR,t DMIO 1EM 101-000-423.000 ��✓1. U0 101-000,441-345 $100.00 S SUB-"3°?��l�'AL. C;t:11viS'IRIT(7f10 1' fi)1�i-AW 4.°1371rQX $3,448.06 1 1� L1,00 PRF -PAZ l I tel 4250,00 MAY 1 1 2001 RECEIPT DATE�INANCE;DEPT BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Forms &Footings �p g Underground Ducts Ducts Slab Grade' Return Air Steel Combustion Air Roof Deck �_(� . p 57 Exhaust Fans O.K. to Wrap Framing Insulation ©( Q „ ®I $ 7 5 T 5_� F.A.U. Compressor Vents Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath 7 _ -Z _ p g-7 Final _ 9�T9 / s=r' Final 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_ Water Piping Sll�l ��• _ S % Heater Final Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection C�,.. (g—p L S—( Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: r 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) % �� . ,...,r--! • ,yrrxry ay.-.�r+.r..-...+�-...-.�.,yt �a+r••-„.+c•r^ri”. �-.tf➢"Li.+�4ir/rK.,d'��'r%/rj��*'�fV-.--�4.s.�a... ..� vim. ,... � :_. • 1� 0 q XO�aI BOX 1504 " 78-495 CALLE TAMPICO APPLICATION ONLY S Building r 1,� /J /�1_LA OUINTA, CALIFORNIA 92253 Address 1 � � �� �7///.../t�/ �Y.l;Nri7'Y�f Owner z),/ Mailing f Address City f Zip Tel. Contractor t - State Lic. City & Classif. ! ,Ca 3 Lic. N � � �•-�' Arch., Engr., Designer • Address Tel. City Zip State Lic. N 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.Susiness 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 that. 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). I] I, as owner of the property, or my employees with wages as their sole compensation, will L do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and ik r 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'1 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'7 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 n 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 if the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of thg 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, 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 I hereby 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 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 applicant -Date- Mailing ateMailing Address City, State, Zip BUILDING: ,TYPE'CONST. OCC. GRP. A.P. Number Legal Descriptions Project Description J• REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line rom Center Line A e Side etback fllgrRpdoperty Line WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION SNo. Size �;r%� Stories No. Dw. Units New,O - Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation PERMIT t AMOUNT Plan Chk. Dep. Plan Chk. Bal. 1 Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line rom Center Line A e Side etback fllgrRpdoperty Line WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION Desert Sands Unified School District 47-950 Dune Palms Road Notice: La Quinta, CA 92253 Document Cannot Be Duplicated 760-771-8515 CERTIFICATE OF COMPLIANCE Date 5/11/01 No. 22006 Owner NameDavid Ross Miller No, 53-175 Street Avenida Mendoza city La Quinta Tract # Lot # 9 APN # 774-062-021 Jurisdiction La Quinta Permit # Log # zip 92253 Study Area Square Footage 1492 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: Residential Addition 500 Sq Feet or Less EXEMPTION NOT APPLICABLE This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 2.05 X 1,492 or $ 3,058.60 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 - Juan Rodriguez Telephone 760T805-1251 Name on the check By Dr. Doris Wilson Superintendent,��'^a- 4, , Fee collected /exempted by Arlene Garcia Payment Received $3,058.60 ' n Check No. Signature 081872 NOTICE: 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 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 FAY. 176080,4,9062, COUI)IONIVEALTH TITLE RECORDING REQUESTED BY:' AND WHEN RECORDED MAIL THIS DEED AND, UNLESS OTHERWISE SHOWN BELOW, MAIL TAX STATEMENTS TO; William ' Thoma's Buff in , Power Brokers B' -O. Bogy; 134 La Quinta, CA 92253 SPACE ABOVE THIS LIt4E FOR RECORDER'S USE The`undersigned grantor(s) declare(s): Grant Deed A.P.N. 774-062-020& 21 Documentary transfer tax is $ --7 ( xy) computed on full value of property conveyed, or 53 - _I;,�S" A v e ( 1) 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, Clyde Burk hereby GRANT(S) to David Ross Miller; a Married Man as his sole and separate proper>'y the real property in .the City of LaUinta . Countyof Slate of California, described as Q Riverside Lot 8 & .9 of Block 207 Unit No. Santa Carmelite at Vale La Quinta, as. per map recorded in Book Pages mf Maps, Records of Riverside County, California Daled March 20, '2001 Signature of Grantor Stai9 of "California' ) County of" ) SS. Clyde Burk Ori " before me, y personally appeared - -- Clyde rk personally known to me (or proved to me on the basis of satisfactory evidence) to be the Person(s) whose name(s) islare subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by hls/her/;heir signati,re(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 T0, Form 3196-4 (6.94*) __...._.. TNTC Cnou el �n• ..._ .. -... RC DISTRICT - PLANNING REVIEW FORM This form•is to be used by CDD 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 SITEADDRESS 53-175 Avenida Mendoza APN 774 _ '062 _ 021 BIN NO.:, CASE NO.': 2001-434 LEGAL: LOT 9 BLOCK 207 UNIT S.C.@V.L.Q. CHECKED BY: Stan Sawa DATE: 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/CORRECTION .Compatibility Review \, Case logged and number assigned Verify legal and APN information Consistent with MDG on file (as.applicable \Ij MDG filing required (5 filings since 9/3/98) Consistency with street/surrounding area: Colors Materials Architecture , Other Requirements: O 40 Certificate of Occupancy City'of La. Quinta- Building and Safety Department This Certificate issued pursuant, to the requirements of Section 909 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: 53-175 AVENIDA MENDOZA Use Classification: SFD Bldg. Permit No.: 0104-089 Occupancy Group: R.3 Type of Construction:. VN Land Use Zone: RC Owner of Building: DAVID ROSS MILLER Building Official Address: . P.O. BOX 722 City: LA QUINTA, CA 92253 By: STEVE TRAXEL Date: 09-19-01 POST IN A. CONSPICUOUS PLACE