9901-092 (SFD)LICENSED CONTRACTOR DECLARATION
heieby. affirm ' under penalty of perjury that I am licensed under provisions of
iD*hap'te'r 9a'(commencing with Section 7000) of Division 3 of the Business and
Chapter
Code, -and my License is in full force and effect.'
License # Lic. Class Exp. Date
506661 '38179
J, a e. Signature of.Contracior-!�._"Zt
OWNER -BUILDER DECLARATION*
t. 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
cor,hpensation, will do,the work, and. -the structure is not intended or offered for
sale (Sec. 7044; Business &.Professionals Code.).i
(7111)1,); as'.,,owne.r.of. the prope'riy, am exclusively contracting with licensed.
coritractors`to-66nsteuct the project (Sec.- 704 , 4, Business-&' Professio I nals
Code):'
am ep . mpt, under Section, B&P.C. for this "SignareaS66
D46 N) .tdre 'of Owne�:,*.,,,-,.m/), 11
7
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty ,of perjury one'6f the following declarations:
clarations:
4 have and Will maintain a,certificate of consent to self -insure for workers'
cbr-ripensation,,as I provided',for by Section 3700 of the Labor Code, for, the
po�rfor ' m an66.o'-f-t'he* Work f . 6r.w hich this'permit'is issued:
I have,,a'ind will maintain workers' compensation insurance, as required by.
Section ; 3700 of th(i Lab6r Co - de,.for the performance of the work for which this
perrhifis issued: My worke'-'r-s' compensation insurance carrier & p6lipy,no. are:
C*ffJMZ Policy No. '01�1 ON VILP !1N1PT;. Al k
(This -section heed not be completed if the permit valuation is for $100.00 or less).
certify that in the performance of the work for which this permit is -issued'
11'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' corrip6risation provisions of, Section 3700 of the Labor
Codd,'l shall forthwith,comply with those provisions.
Date: Applicant
Warning; Failure to secure, Workers' Compensation coverage is unlawful and
§half subject an employer to criminal penalties and civil fines upto$10.0,000, in
addition to the'cost of compensation, damages as provided for in Section 37.06
of'the iheLabor Code; interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
fbr,t.'a','.permit subj6ct to the. conditions, and restrictions set forth on his
ap p-i16a:tion.`.
is i 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
a p&mit
n�'--issued as a result of this applicaton agrees to, & shall, *indemnify,
ho18,ha'rmle'ss the City of La Quinta, its.off ice rs, agents and employees.
.Aqy';pqrmit issued as a result of this application becomes null and void if
mork. is, not commenced. within 180 days from date of issuance of such
". ., rmi "'. t , or .
pe,cessation of work for 180 days will subject permit to cancellation.
I certify that'I ha4 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
b6i4str6ction;, and hereby authorize representatives of this City to enter -upon
the above-me'4oned property for inspection purposes. r
gnat/Z
ure i (Owner/Agent) Date
,PERMIT#
BUILDING PERMIT
'8." - RAC
DATE VALUATION S91,41f LOT I T kio,
'OB—s'TE610
ADDRESS 54- "M 10A IJ
APN
774-27C�IdS'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1%a%. . L S.L.J
C "I A'D v GEMERMI CCOINM-�A=10,
JACK 111' A 01 1 nV
!.l"1.,01. � E,X-,k -A . %.Ab,A
51-220,AVENI.MA CAPLRANZA
$1-220 AVENIDA CA"ANZtk
fik 922-53
LA. QU!NCA
_�Jft
LA. (, N TA CA. .0225-1
(`760)j5644 3511
USE OF PERMIT
SWOUR. PAUH, Y OWEILIKO
UD - P81WfYU01 1,' NOT INCLUDS RLOM WALLS GWPOOL
TrZ ACTCOL4.STRUC rl(YN 1.505100 SF
PORCIVI)AVO 142.00, 181F
SP
- 1i 0 1re NT
ds"17 OF comsl L-. 1n. 01 N.
92 US. 190
-IT"RhOT FIETi SIIJUNIARY
C0N&rKUC,X Kill FE1i 101-00t)-413-000
PIVAN (ITECK, F -f CR
10 .0 5
NfCCRA341CAL Fly ,T 101-000-421-000
1JX!X_-J'K1CALFFJ! 101-000-42"k S 125.24
P11. -OMB IWO rl1().1405,4194)OD
101"000441-000
till At',+t,hlCt fvu $20k
225-004-&6-3421) -1 S. 5 1
VR'Ckr1J4,QF,. P(,jk I Q -(iM-44 MOAK)
SUB-TKYrAL C,'0NS`MQC71(_YKAW,) PLAN CHECK
EPkE 1)
L SS 2 S -plu, FE"L's
4250.00
T(YFAI, PfERNUTFL' ES DUENOW
AA
NEGN)i-
V 1X
IDATE
BY
DATE FINALED
INSPECTOR
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—
y
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
3 Q
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
,r
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
Heater Final.
Water Piping
EePlumbing
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 T f
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: '
.�.a;� fes'; .. a • i" l}.:i
Desert Sands Unified School District
47-956 Dune Palms Road
Notice: La Quinta, CA 92253'
Document Cannot Be Duplicated 760-771-8515 `
CERTIFICATE OF COMPLIANCE
Date 2/22/99 APN # 774-270-023
No. 18380 Jurisdiction La Quinta
Owner NameJack Clark General Contractor Permit #.
N0.54725 Street Avenida Rubio Ug #
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 1,5.05
.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 y -
This certifies that school' facility fees imposed pursuant to Government Code 53080 in --he amount ofr�. f r ` ; r
1.93 X 1,505 or $,.2,904.65 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/ Valley Independ. Bank/Jack Clark Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto Payment Received $22904.65
Check No. 183137
Signature 44Ld4161),
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 prolezt 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 Dislrict('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
QLD REPUBLIC IITLE CO,.
RECORDING REQUESTED.BY: ..
OLD REPUBLIC TITLE COMPACOMPANY
98.7516KC 108799-13
"RLMOLO�AXRWINI WOW,D.
JACK L. CLARK, JR.
540,350 AVENIDA HERRERA
LA:QUINTA, CA 92253
i2A D ZO -• O/ 5
54-725 A rr99810330717
RECEIVED FOR RECORD
PAID AT8:ODAM
Transfer Tax AUG - 7 1998
Co. Recorder A R.,,,, mw
d pQe Comb, Cam
Recorder
SPACE ABOVE THIS ft'!MM
APN: 771-271-C
GRANT DEED 774 2'7 1 023
ESL
IL
'S USE
The undersigned grantor(s) declare(s):
Documentary transfer tax is $35:20
(XXX) Computed on.full value of property. conveyed, --or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of , and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
WILLIAM R. RILEY, TRUSTEE OF THE WILLIAM R. RILEY TRUST (1990)
hereby GRANT(S) to
JACK L. CLARK, JR., 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 10 AND D OF BLOCK 270, UNIT 25, SANTA CARMELITA AT VALE"LA QUIN^-A, AS
PER MAP RECORDED IN BOOK 19, PAGES 50-51 OF MAPS, RECORDS OF RIVERS=DE
COUNTY; CALIFORNIA
Dated April 27, .:1998
State of California
County of Riverside } S.S.
On August3,. 1998
before me, Kelly Collier
personally appeared
William R. Riley
personally known to me. (or proved to me on
the basis of satisfactory evidence) to be
the person(s) whose name(s) 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 th person(s), or the entity upon
behalf of whi h the p son(s) acted, executed
the instrumen I
WITNESS my h a :d . ff ' c�ial seal.
Signatur
;MAIL TAX S EMENT T0: . SAM,AS,AWVE
WILLIAM R. RILEY, '3RUSTEE
OF THE WILLIAM R. RILEY TRUST (1990)
�ry KELLY =OILIER
Ccmn� i-1057217
NOTAP`.''"1BLr CALFORMA
• 7rfWS +Corm
My Cone 1xp�,s May 28.1M
is area for official notarial seal)
COMA).. a t0572
RiversjoCOub
WVes Mw 28.190
'l.
COW
is area for official notarial seal)