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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 # 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:
( ) 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,bontracting with licensed
1Xo tractors to construct the project (Sec. 70�j' Business & Professionals
Code). t�l
( ) I am exempt under Section B&P.C: forthis reason
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Date Signature of Owner 1 `!
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one; oV,Abe following declarations: a,r
() I have and will maintain a certificate of cora ent to self -insure for workers' ;
compensation, as provided fog; by Section 370 of the Labor Code, for the !
performance of the work for which this permit is: ssued.
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 gTAf.IIIr�t�l)^, 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
dde, 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 applica ton 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
theabove-mentionecl property for inspection purposes.
Signature (Own er/Agentf,�� ��� �j _ ate
BUILDING PERMIT PERMIT" ��`a ` s 7
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VALUATION y,y ryryLOTnn TRACT.
DATE f / J
JOB SITE
ADDRESS 521 -WS S AVET�i��1�i, CAP--W.+e �i�u
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CURD] CLACI M+`
01AWNR "3TUITLT 04
'
USE OF PERMIT 1
-••..4131. yYY�� c 1`rw.7ra*a,'f t��, .,.66 �.7.M.7'F17'
.
SMA9t2 iQ.IFT. LAr[14U 'i2ZnMIT szO 034 T aNCL!TDR, r1f.0C'K WAILS.
1' INCE;3,P001, OR SPA. WIVA;VOIE HAMIT POP. TAi'ii'I' A f J, ei'PiWAC'11.
!S IkeoulR.i o r;tc. m PJi:".). w welms Ulp'n.
TRA"T CONS?"Rt,lt' TION
? PORCH)PAT'IC� . 134.00 SF
WAG= WORT 497.efa �t�
C.ON19 fI#i!CT 1014 i119I, I t1I-GO0-41 S - (KI 0 IEtS35.3t�
IFr ,kH CE1t^'.0 C ME I i; I _4100-1439-3 A a s4 s?O.Fra
PFR PG;TCOAT '101-00C-439-3'88 4=100
A6WN.A1?1rk,LM1 is
EIA T.ii t;ALIRE lgy:1•0001 421-o":'i st,s5.:6
PLI7,MIP-10 M. 1.011.0fX)..ra.I 9 -OC -0 *??R."ts
ST2OIOMOTIOX ,n"l T MiD 1101-000-241•vCO fif
ORAD110-0 VEX, 101-6rA-423-000 315. !M
XX EW! ER sm PACT ITY-E
PT UC`13VPLAN t C11 -i" 00-0. It .343 � l UB•fiC
z . ,tICi:TJ;k<; Aly-I>T.at #--I t{ C'tC,5.+t
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JUN lg 2003 �, �, �x.��I�x� a���� a��r~�,�•���r
��.��tiaa.a;�
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE F
:6Y, _
DATE FIPIALEJD
INSPECTJbFJ
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
/ Q
Exhaust Fans
O.K. to Wrap
—
F.A.U.
Framing
A - -0 3
Compressor
Insulation
O
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Q
Drywall - Int. Lath
_
% Q
Final
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
l �j
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)
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 (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 1,912 S.F. or $4,091.68 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 C/C Provident, John Clapinski Check No. 97914
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exeLdby atrici Barbuzza $4,091.68 1$0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 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 Distdct('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
f Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is o determine: 1)
that the proposed housing design does not duplicate the same architectural sty a of any house
within 200 feet of the applicant, and/or 2) if. there is a need for the applicant to ile for Master
Design Guidelines. If the applicant does need to file a Master Design Guideline, p ase transmit
this information to the Building and Safety Department as part of your correction ist. Please
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attach additional explanations as necessary.
APPLICANT: '�0
SITE ADDRESS: :5:;,) - qa 5 A0&'t"-bA�-
APN X173 - Z Z f - CASE NO.: 79
LEGAL: LOT BLOCK /sem UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY: 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
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:
Architectural design features
Approved bv: 2
0 Planning Commission _.._._..,—.
0C' y Council r
Community ev. Dept.
.f.'
ols PRE
CaseNo. ....------
Exhibit fA- ..r-----
Other Requirements:
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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 Stair
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
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012
FAX (760) 777-7011
7- m O n7
O SI TURE/DATE
AV6 ibA—�R—t2pNZA
PROPERTY ADDRESS
PERMIT NUMBER(s)
American Title Insurance Company -
Escrow Division
72393 Highway 111, Suite B
Palm Desert, CA 92260
(760) 773-3776 Fax (760) 773-3228
SALE ESCROW INSTRUCTIONS
TO: American Title Escrow Date: July 24, 2002
Escrow Officer: Kathy Yasi
Escrow Number: 02 -2937 -KY
AMERICAN TITLE ESCROW CONDUCTS ESCROW BUSINESS UNDER LICENSE IDENTIFICATION NO. 371
ISSUED BY THE CALIFORNIA DEPARTMENT OF INSURANCE.
Christopher A. Clapinski and Jodi Clapinski, (hereinafter known as Buyer) agree to purchase from William R. Riley,
(hereinafter known as Seller) the real property setforth herein per the terms, conditions, consideration and instructions
hereinafter stated. The Seller and Buyer herein shall deliver these signed escrow instructions to American Title Escrow,
(hereinafter known as Escrow Holder).
Terms of Transaction
Buyer has deposited to escrow by Personal Check the sum of
To Complete the Total Consideration of
$ 45,000.00
45,000.00
Furthermore, I will execute and deliver any instruments and/or funds which this escrow requires to show title as called for, all
of which you are instructed to use on or before August 9, 2002, provided you hold a Policy of Title insurance with the usual
title company's exceptions, with a liability of not less than $45,000.00, covering property in the City of La Quinta, County of
Riverside , State of California, described as follows:
„I Lot 9, Block 156 of Santa Carmelia at Vale La Quinta, Unit 16, as per map recorded in Book 18, Page(s) 99 of Maps, in the
Office of the County Recorder of said County.
commoNLY KNOWN As: Vacant-APN#773-321-009, La Quinta, CA 92253
--> 52-12S !♦ v£. 444M417-#4
SHOWING TITLE VESTED IN: Christopher A. Clapinski and Jodi Clapinski, Husband and Wife as Joint Tenants
SUBJECT TO:
(1) General and Special County and City (if any) Taxes for the current fiscal year, not due or delinquent, including any special
levies, payments for which are included therein and collected therewith.
(2) Lien of Supplemental Taxes, if any, assessed pursuant to the provisions of Chapter 3.5 (commencing with Section 75) of
the Revenue and Taxation Code of the State of California.
(3) Covenants, Conditions and Restrictions, reservations easements for public utilities; districts, water companies, alleys and
streets, rights and rights of way of record, if any; also exceptions of oil, gas, minerals and hydrocarbons, and/or lease, if
any, without the right of surface entry.
INSTRUCTIONS TO ESCROW:
ALL CASH TRANSACTION This is an "All Cash" transaction and no financing will be secured on the subject property.
Additionally, Escrow Holder is instructed to close this escrow without regard or concern about fire insurance coverage for the
subject property (Unless property is a Condominium/Townhouse, in which case, Escrow Holder's only concern is to transfer
the Seller's interest in the master policy to Buyer at close of escrow). Buyer is to obtain their own insurance coverage outside
of escrow and release Escrow Holder from any responsibility in connection therewith.
CLOSING COSTS: Seller herein agrees to pay all Seller's usual costs and charges in this transaction which may include, but
are not limited to the Owners Policy of Title Insurance, reconveyance fee, if any, recording fees, Seller's escrow fee and
Certificate of Occupancy
V _ Tiat 4 4 Qum&
G� OF'T9� Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 52-925 Avenida Carranza
Use classification: Single Family Dwelling Building Permit No.: 0306-287
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: Chris Clapinski Address: 79-480 St. Margaretts Bay
City, ST, ZIP: Bermuda Dunes, Ca 92201
By: Daniel P. Crawford Jr.
Date: 10/10/03
Building Official
POST IN A CONSPICUOUS PLACE
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