0005-164 (SFD)LICENSED CONTRACTOR DECLARATION
I heieby 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.
"yLicense# Li Class Exp. Date-
4253 1>'31►'2t
Date CC�Signature of Contracto
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: t
(` ) 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. .
( ) 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 S'TATF i i3F3O Policy No. I �%990-tO
(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 inany manner so as to become subject to the
wo�(ers' compensation laws of California, 1hd,;gree that if I should become
sUblect tQ the workers' compensation plovisi'ops of Section 3700,01f the"Labor
Code, ..s all fort ith comply
Date: WAoolical
Warning: Failure to secure Workers' Copensation coverage is unlawful and
shall subject an employer to criminal penal 'sand civil fines up to $100,000, in
addition to the cost of compensation, damag; 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 1,80 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
cons uction, and hereby author'ze representatives of this``Gity to enter upon
the bove-mentioned property fo� inspe -tion purposes.
ignature (Owner/Agent)`-�
a BUILDING PERMIT PERMIT
L
DA� VALUATION LOT • � TRACT
f fJy 4 p
r -
JOB SITE 7 0
-74
APN
ADDRESS j � �•�
.51—'rib A.�''ii�VA0.J49IRU-010
..',•, .773-a<'�i�^yr.��
OWNER
CONTRACTOR/DESIGNER/EN INEER
DAM W.
PACWIC ES COWS11tI (TfION
)? 19 S: T11.1WONT
1919 511REM X14 c
L) -A 1Z7";1' C,` 92054
S Oc``1±:lihT�113�, i CA 92054
(760)967�0069 Cry 1955
USE OF PERMIT
Si OLB FAM71 Y DV '.J.WG-
SM-P3:RMIT DOES NOT INCLUDE BLOCK MALL OR. POOL. LOT Y EIWCK.'
22 UNIT 0
TRACT CONSTRUCTION 1,421,00 8F
"
PORCHIPATIO 35.00 S
0A AWC ORT OF)
5 FT. WOOD VENCE 300.00 Li
'RSTMATED CIOSJ. 01" `i COXWrRU( AJ,b?E7
a7.9ad. tFs7adW
1 :RMT ly'1u'E SUPANA 2Y
CONSTRUCTION FEE 101.000.418.000 $594.30
PLAN CHECK FEC 101-000-439«4118 $500,07
MECHANICAL FEE 101.000.421.000 Smoo
ELt (,TR1CAL FEB. 101-000-4420'-000 $129.,320
1'1.;UMBING VVE 101-000-419-000 S116.71
OlLkD1NQ FZ9 101-000-423-000 $20.00 ,
%&FLOPRR IMPACT FRE $i,9rlm
PRECISE PIAN 101-000-441-345 $1,00.00
F'f+"E DEPOSIT 101.000.439-318 -5250.00
SETH -TOTAL C,ONSTRUi'1.2ON AND PIAW C'Y-MM'
$3,421.56
t n-�IS33 PRE -PAID FM
4250,00
1'OT'AL F M&r M1, S D"UE NOW
$31171.56
RECEIPT
DATE
Y
DATE FINALED
INSPECTOR
1 L/ N4-1 I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
pro
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Tjf%57
Compressor
Insulation
. B,p
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 ou
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
44Plumbing
Heater Final
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole Ar. 2 . CPO
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:
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 5/26/00 'APN# 773422-009
No. 20482 Jurisdiction La Quinta
Owner NameDavid Miller Permit # 0005-164
S I "I No. 547Street Avenida Rubio . Log #
.City La Quinta f Zip 92253 Study Area
Tract # Lot # 7 Square Footage 1421 t
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
This certifies that school facility fees imposed pursuant to
Government Code 53080 in the amount of
2'.05 X ,1,421 or, $ 2,913.05
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 Check/Capital Bank of North County
Telephone- '_760-967-0069
Name on the check
w . =�.
5 «. .
r
a
By Dr. Doris Wilson
Superintendent
42
Fee collected /exempted by M�'Y Ann'L. BorJa
Payment Received -r ;9 13.0_ 5 � +
Check No. 17915
Signature0�4
&Ai�.. ,
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
si _ 7,44o&E,96010 &56I sib P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address SUE. j3t 0 LA QUINTA, CALIFORNIA 92253
Owner
1(zz>
Mailing /7/2
Address
City
62'C/+oJS /cig
ress
City
,h ;. ' ♦ ..tit: .
APPLI ATI�Y
r
i_ BUILDING: TYPE CONST. OCC. RP
5 • 1 osMoNr'r A.P. Number -7 TS �� ZZ - oa> c,
Zip Tel.
Legal Description Z �T � "J�'fy�IT�
Project Description A)a�k->
Zip Tel
J
State Lic. City /
& Classif. Lic. #
Arch., Engr.,
Designer
Addr,Qsp Tel.
City ZiState
,f4Qu 0--m �2ZE3 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,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 or not more than five hundred dollars ($500).
I-!. 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 1 1, 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 1 am exempt under Sec. B. 8 P.C. for this reason
Date Owner
r
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
FI 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 :pennif is for one hundred dollars J$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, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Coda, 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 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 sof this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant -Date-
Mailing
aleMailing Address
City, State, Zip
Sq. Ft: Q No`.
Size, I ` Z Sto
New Add ❑
EStfmate0 valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I. s
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
No. Dw.
ies Units '
\Ite)❑ Repair ❑ Demolition ❑
AMOUNT
f\>
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 INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
MAY -12.2000 1:50PM COMMONWEALTH
RECORDING REQUESTED BY:
CHICAGO TITLE COMPANY COMPANY
9929KC 207056304
WSEN RECORDED MIL THIS DEED AND,
UXLXSS OTHMMSE $ROM BELOW,
KAIL TAX STATEMENTS TOO
DAVID ROSS MILLER
1719 S. TREMONT
S. OCEANSIDE, CA 92054
N0.899 ' P.1i4
51-1.40 Avv, - -vsto
SPACR ABOVE THIS LINE FOR RECORDER'S USE
GRA DEED APN: 773-182-009
The undersigned grantor(s) declare(s):
Documentary transfer tax is $14.30
(XXX) Computed on full value of property conveyed, or
( ) Computed on•full value less lens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of A and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
FRITZ S. BURNS FOUNDATION, A NEVADA NON -STOCK, NONPROFIT CHARITABLE CORPORATION
hereby GRANT(S) to
DAVID ROSS MILLER, A MARRIED MAN AS.HIS SOLE AND SEPARATE PROPERTY
the real property in the City of LA QUINTA, County of Riverside, State of California,
described as:
Lot 7, THE NORTH HALF, Block 22, Unit No. Z „ Tract Santa Carmelita at Vale La Quinta, as
per map recorded in Book 18, Page(s) 55-56 inclusive of maps, in the office of ,the County
Recorder of said County.
Dated Kay 12, 2000
State of California
County of } S.S.
On
before me,
personally appeared
personally known to me (or proved to me on
the basis of satisfactory evidence) to be
the person(s) whose name(e) is/are 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 his/her/their signature(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 TAR STATBNEETS'TO:
,
FRITZ B. BURNS FOUNDATION
A NEVADA NON -STOCK, NONPROFIT CHARITABLE
BY
Name/Title
BY
Name/Title
(This area for official notarial seal)
f
Je
RC DISTRICT - PLANNING REVIEW FORM *4k
This form is to be used by CDD staff for review of single family dwellings in the RC ( ove.Resideffftkl)
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 DAVID MILLER
SITE ADDRESS 51-785 Avenida Rubio
APN 773 _ 122 -009 BIN NO.: CASE NO.: 2000-225
LEGAL: LOT 7 N Y-1-1 BLOCK 2 2. UNIT 2 S.C.@V.L.Q.
CHECKED BY: Greg Trousdell 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
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
I ( Colors
1
Materials
Architecture
PC
P
CJ
Other Requirement (((c .
71/1.
ZLI2I -�OL 5-617
Certificate ofocc'u'
pancy
City of La Quinta
Building and Safety Department
t
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
ol%wing.
BUILDING ADDRESS: 51-740 AVENIDA RUBIO
Use Classification: SFD Bldg. Permit No.: 0005-164
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RC
Owner -of Building: DAVID MILLER
Building Official
Address: 1719 S. TREMONT
City: - OCEANSIDE, CA 92054
By: STEVE TRAXEL
Date: 09-18-00
POST IN A CONSPICUOUS PLACE