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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# t Liic. Class
33 T Exp. Date
CQ.rD`.�.3 1 B C36 Cr4Z iii 1 /r�t� 1 s� /
Date, '_+ '= Signature of Contractors
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). , ' s
( ) 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.
(,d) 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 0TAT lar F'D4D Policy No. 1$176789
(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 tai 4
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 permitJo 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. y '
Signature (Owner/Agent) 4.41 Date* A_ e').2t;
BUILDING PERMIT s PERMIT# ;¢
DATE VALUATION LOTi TRACT .
5�►7.5.!,t3 7 Myr 5S
...' f - , ^�
JOB SITE -
ADDRESS 51-625 AYMitDA Car.+4�i RWM
APN
773-124-019
OWNER
CONTRACTOR/DESIGNER/EN (NEER
UME9 F. .iC1AP
C. B11"AP, SR-
P.O. 3(YX 297
`73.300 VA)DIMIZEM. LME -
PALM DEaS.►:TZ' CA 92261
PALM DEBW CA, 92261
(760)777-95 72 C.B1.4 290
USE OF PERMIT
OLF, FAT".,`x' DMLLMG
1604 S.F. SIYf:D IZPJ4IT.D0,V4-NOT'!.`NCLUIaf-0HLOCIC WAU, POOL OR
DRiVEWAY APPROACIL 75% REDI C&D PIAN CHECK KE FOR M LTIPLF
I}I. A14S SAUR, k1.0'WE3'
'I'RACT C ST11 l . '1014 ;I,6IIco OF
1'ORC Hd;9a'�:CIf3 3117.00 SI`
GARAWCARPOR i'
MITM) COST C)F C.C?N-91RUt-0K
CON S'I'i ITC 10N FFF, 101-000-118-000 0"151)
PLAN Citi?. X FEE 1011 -WO -439-318 $131,24
;
EX DEPOSIT 101.0..00-439.31.+1 •Va50.,00
MP, "AMCALF'1 ,, 1014",-42.1 -.000 $59.00
PU6.TRI.CAL FEE 101.000.4ZO.00 a $1I156
PLUMBIN0.71% 101-000-419.000
STRONGM0'I'I01T P • RIA.10 101.000441.000
GRAMNO FEE 101--000-423.000
DY,,V %0FFit IMPAC A FEE %2elvs.00
PrIarlis PLAII 101-6.00-441 -145 � I tIf3.Oh
4• -
Sp S PR&PACD PRES
b`E2�50,00
Ijl
FEB•1212003
r
CITY OF LA CIUINTA "FINANCE
DEPT<
BY
DATE INAL
INSPECTOR
?t
8 r1 Li
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
—
Underground Ducts
Forms 8 Footings
O
Ducts
Slab Grade
�O
Return Air
Steel
_� _
Combustion Air
Roof Deck
L —
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
G/��G0
Drywall -Int. Lath
.i�
Final
17U3
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
Waste Lines
Electric Final
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
tJEic)3
Final
Utility Notice (Perm)
`��
Date 2/21/03
No. 24166
CERTIFICATE OF COMPLIANCE
Desert Sands'Unified School District
47950 Dune Palms Road
La Quinta, CA 92253
(760) 771-8515
����lFlEDsc�
Q BERMUDA DUNES r
RANCHO MIRAGE CJ
INDIAN WELLS
PALM DESERT ,y
LA OUINTA r'
"(7INDIO^i
O J
Owner
James Belknap
APN #
773-124-019
Address
P.O. Box 297
Jurisdiction
La Quinta
City
Palm Desert Zip 92261
Permit #
0301-183
Tract #
BLK 56
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street S.F.
Lot # No.
Street S.F.
Unit 1 7
51625 Avenida Carranza 1604
Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments Certs #24163 through 24167 used for CC #305788
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 (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,604 S.F. or $3,432.56 have been paid for 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/La Jolla Bank - James Belknap Check No. 305788
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempt y Shar Gilvrey $3,432.56 So.00
^ Payment Recd Over/Under
Signature G
NOTICE: Pursuant to Government Code Section 66020(d)(1), this rve 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
4 4 Q" , `3 6> [ - " �"
P.O. BOX 1504 APPLICATION ONLY
Building F5 78-495 CALLE TAMPICO
Address LA QUINTA, CALIFORNIA 92253
Owner
Mailing y 7 ^
BUILDING: TYPE'CONST.OCC. GRP.
Address A.P. Number ! A_ IX( _ 0 VR
Zip Tel ry A /
Legal Description _ [ �S�
C ntractor Proje escription
Address ^
ty Zip � Tel.
State Lic. City J(O
& Classif. Lic. # Sq. Ft. No. No. DIN.
Arch., Engr.,
Size Stories Units
Designer Ne Add ❑ Alter ❑ Repair ❑ Demolition ❑
Addr s Tel.
4 0- 36dS
Ci Z__11
State
(1. .,�- /__1_I 11 Lic.#i4i 1.2!
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,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 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 applicant to a civil penalty of not more than five hundred dollars ($500).
l: I, as oner 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 ate not intended or offered for sale. If, however, the building
or improvement is soldwithin 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.)
17 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. 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 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. after making this Certificate of Exemption you should become
subject to theWorkers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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.
1 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 Address
City, State, Zip
nation
PERMIT AMOUNT
Plan Chk. Dep. Z.S
Plan Chk. Bal.
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
Side Street Setback from Center;.12, el,
Side Setback from PropeFty.ine 11
FINAL DATE
Issued by:
Validated by:
Validation:
�Y
WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE
I
RC DISTRICT - PLANNING REVIEW FORM
r This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine: 1)
that the proposed housing design does not duplicate the same architectural style of any house
within 200 feet of the applicant, and/or 2) if there is a need for .the applicant to file for Master
Design Guidelines. If the applicant does need to file a Master Design Guideline, please transmit
this information to the Building and Safety Department as part of your correction list. Please
attach additional explanations as necessary.
APPLICANT: a m e S 8e i. K r� n P
SITE ADDRESS: 5/*— (p d S Ca � 19- a n z c�
APN 1-7 3 CASE NO.: X53
LEGAL: LOT. BLOCK UNIT
CHECK AND APPROVED BY:
S.C.@V.L.Q.
1OL"It l
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
Verify legal and APN information
Consistent with MDG on file (as
applicable)
MDG filing required (5 filings
since 9/3/98)
Architectural variety within 200
feet of the surrounding area:
Approved ate He o
Planning Commission
Citv Council
1. Communi!ty Dev. Dept.
1 itials ALIV
Architectural design features
xhibit A -
11 With Conditions
Other Requirements:
Certificate of Occupancy
City of La Quinta
Building. and Safety Department
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:
51-625 AVENIDA CARR.ANZA
Use Classification:. SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction: V -N
Owner of Building: JAMES BELKNAP
Building Official
Bldg. Permit No.: 0305-082
Land Use Zone: RC
Address: P.O. BOX 297
City: LA QUINTA, CA 92253
By: KIRK KIRKLAND
Date: JUNE 17, 2003
POST IN A CONSPICUOUS PLACE