9907-103 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) ch License,# Lic. Class Exp. Date
Q LO _50&'ki 7 P 3:1/3 i t2 0i
oZO r— /ate�3' Signature of ContractorAl
r- U CO OWNER -BUILDER DECLARATION
LU Wd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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
N Date Signature of Owner
ON
rn
O_ Q WORKER'S COMPENSATION DECLARATION
p zCc I hereby affirm under penalty of perjury one of the following declarations:
LO
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X LLI �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) 1 have and will maintain workers' compensation insurance, as required by
O Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
'IT z Carrier Policy No.
ob ON
J(This section need not be completed if the permit valuation is for $100.00 or less).
(vv) I certify that in the performance of the work for which this permit is issued,
I gall 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
3 subjedtto the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with.those pr visions.
4lfate: C Li Applicants t Til i 1l"h —
Warning: Failure to secure Worker 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
• correc)�l 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-mentioned property for inspection/purposes.
✓Signature (Owner/Agent) /`� r IL / (! A ! %. Date S `)4/
U ��' T
BUILDING PERMIT PERMI
91,11117-403
DATE VALUATION s1�.i+};ti 1} LOT 14 TRACT BI•K +2 11 1 4
JOB SITE i
ADDRESS r :}1- TILi�E'.l�IIiA Cf rll1\t/rt}S
APN 774•}8i -4i1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
.1ACK' C!,AXK Ii:
'ACK C.'IAUK c7,:"iF RALCc:)1%MCAC":C'�k
51-220 hVaNIDA l::AARAP,17 l
Si •220 AVZ•rMDA C_A.iZ12tltNZtk
LA l; UIIv I'A CA 9229:t
LA Q#1.if'N' A C;A V! ?53
USE OF PERMIT
Pt"'2RW T fes; E.S i\ita i74t: Lt;DL•; i3LCA,iti ,ji+i OR i'' 1vi,. VLAIN CHECK
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ _ S_
?'
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
/ o o
F.A.U.
Framing
Compressor
Insulation
$ — — bo
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
5 -_ op
Drywall - Int. Lath
, ov
Final
Final !
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs _ !�
Footings 7
_
Electric Bond
Main Drain
Bond Beam
410004
Z
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
2 !
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
arcs S
Encapsulation
Gas Piping
Gas Test
'5
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole y/= S 7
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:
�__�-�^,,.,,,,;..„,,.,1=2i;i.�ic,o'�+:�-.ra�.�..tt::f.:.;;;�'ckis�c :�p�'e[�' � ��:,�."J�'."�-1•Yr�^':.,.�.:,..,�'y�-7�
*04,,(042 P.O. Q
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BOX 1504
Building 78-495 CALLE TAMPICO APPLIA O Y
Address ��' �,� Q. kc (CL n -z& LA OUINTA, CALIFORNIA 92253
Owner
gzIt- Clew `L Jr. BUILDING: TYPE'CONST. OCC. GRP.
Mailing //��
Address � ( ..� q:2 A jp C4v V MJ`7 CL A.P. Number 114- Oki— G) t
City v i W tD Zip Tel. Legal Description 101 1 L'1 61021& A:�� al
Contractor
Zip
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
Lic. #
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. 7031.5,13usiness 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 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 (S500).
F2 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 I 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 ] 1 am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that 1 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
r7 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 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' 8, 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
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 it 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
Description
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. 250
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 Line
Side Setback from Property Line
FINAL DATE
INS P : -TOR ` •�
Issued by:
Date ��,�� Per
�g'
JUN N
Validated by:
Validation:
r— f r'...
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 12/28/99
No. 19850
Owner NameJack Clark, Jr.
No. 53-470
City La Quinta
Tract #
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Street Avenida Carranza
Lot #
Type of Development Single Family Residence
Comments
APN # 774-081-011
Jurisdiction La Ouinta
zip 92253
Permit #
Log #
Study Area
Square Footage 1506
No. of Units 1
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
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 1,506 or $ 2,906.58 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be iss4-d_
Fees Paid By CCNalley Independent Bank/Jack Clark, Jr. Telephone,,_
Name on the check
Yf
r
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre Payment Received $2,906.58
Check No. 209506
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation peril for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
L
RC District Planning Review Form
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District, in order to. determine the applicability of compatibility issues -6 r need
to require the filing of Master Design Guidelines by the applicant. It shall be transmitted to
Building & Safety as your correction list. Please attach additional explanations as necessary.
APPLICANT: Jack Clark, Jr.
PROJECT
ADDRESS: 53-470 Avenida Carranza
APN: 774-081-011...
LEGAL: LOT 14 , BLOCK 223 , UNIT 21 , S.C. @ V.L.Q.
CK'D BY: Leslie Mouriquand . .
BIN N0:. CASE N0. 99-91 CHECK DATE:12,2b0,1
Inform the assigned Building plan checker upon. your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assigncase numbers.
REQUIRED ITEM Y I N COMMENT/CORRECTION
:{.}:•�.}ri{^:::\^i:.:.:{'r'•�'p{":�::},i\^i\\^.,^�{ti::\•..}:.\,�,�p,4.\...:�\\:...:.^'\i2G•<:i:::$:'i\:{{;}:6:•':i\}}:�: L.. nn\ .;(..\D'.•iS$x{•�
tiC>5,':::'i.`:;j`(.}},""•}\\:�4�Lry`.i?2:::y;.\ti}:}}.{.{.\'v'i4�TJ.�•.:}:•14� C::" :•i\ti}`^•::::i4'\ti} 1 •.K..'i\\'444{f i4 'G:;} ' t•ti.`^� \}'\ M:•�A`O i�\•i .
..yi■ n: .. \�••}}' i .:� • •',\:`moi• i\ ��k\`•.�; •i h',1 • n<}N•,li•}I�,.'I" �:�$•i. fi ^t R^ hv} •.' n :
�yw�. tH'.' `y; }�{:,:: vn.• 'h �i�::{:;^r�:'xti:.. •.:�\\{t•: r i:::\•. \%\v�.ih.*�\:u�{h�'i^.: •.h:; \�.
}:1��. •.ti^'�:..�^f��pp� 4Y' \^ ^i:•ni�:\^ :.\\. \,}` ::
�Gf'3.I�.::A�13+F:�\'{•.+:.:.:.nF:•:.::...}i....$.........\..n\.x..::,.v: . ,... :
Case logged and number assigned
-
Verify legal and APN information
Consistent with MDG on file las applicable)
MDG filing required 15 + filings since 9/3/98)
7 _,RZ 2f
Consistency •with-street/sur-rounding area: -
Colors
Materials
Architecture
OTHER REQUIREMENTS:'
The zoning code, architectural and landscaping manuals, and/or assigned inspector should
be consulted where uncertainties arise. The completed checklist shall be maintained in the
Building &' Safety address file.
' r. � ..-• - v- ,..._ r. .. ,�..-. .. .. _ .. ._ ..,err
sr �
Sladden Engineering
6782 Stanton Ave., Suite E, Buena Park, CA 90621 (562) 864-4121 - (714) 523-0952 Fax (714) 523-1369
39-725 Garand Ln., Suite G, Palm Desert, CA 92211 (760) 772-3893 Fax (760) 772-3895
Date a.- `-� 'I . J Q
Job No.
FIELD MEMO
Project Name r)6 !" 1/1 -4 %f-4 t2 ADZ q Client:
Site Address `` �- 0 f t V 11 /4 ,4?r iti
Job Phone
Work Done
Test Summary / Footings Inspected
Test
No.
Location
Elev.
Dry
Density
Moist
% Relative
Compaction
Ref. Max
pcf
Moist
%
+%
i"
Comments'
oye- 1CJ moi'.
Field Tech
At' z (. F,IL
Super. or Agent
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.