0105-036 (SFD)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
1 Date ko Signature of Contractor ✓ �� ""�T
LDER 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).
( ) 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 Policy No.
aRAPT .
(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 th 1e isi0,S. �e.•�•"
Date: "> , Applicant --
Warn i ng:.,Failure,tolsecure*W6ek6r§"Compensation
pplicant_Warning:..F.allure,to°secure*W6ekers"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 bis
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, indemnity
& hold harmless the City of La.Ouinta, 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 issuanceof such
permit, or. cessation of work for 180. days will subject permit to cancellation.
I certify that:] 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:.,
Signature (Owner/Agent) d•^'�"7 •=•� • Date —��(
,UILDING PERMIT k PERMIT#
DATE. VALUATION LOT 0.1TRACT y,
71 B278 U25
JOB SITE
ADDRESS 1E { '.
APN /
��I 630 a h.�aMMOAR.M0
OWNER
CONTRACTOR �
A7!1'�1�9VAX1 �+�"'.l4JA."�,7.dt� � ,Kb7iA;rJ.tl`S ,X�d.J4
�/yDESIGNER
q/�E{Ny�I(N.�EER
,iYdbFd F. •6,P %i, TJ VJ.l.JJ.I..Cr1N.A7
40-447 RAMMUM COMT
T! -898 IMN-TWAY 113
'IMI. . 0X1JH 1r CA 92260
I.A, i2vwrlt, CA 92253
USE OF PERMIT
W111 a iNiSMIT rXIES 1401, INCI.,t1l:yK 8LOCK '6'a*'A1,V3, P001, CfE;..0R1`F7KKA*f '
UMCT CONa�v`v�RUCTION
SP
J
}
CONSTRUC PO M, 101-004-418-000 $601,54
M
PW4 CHWIr, FFM 101-000-439- $566'77
FSI✓ UPPOSIT 1014WO-439 -318 4201013
$53.50
uC•fiyG�3y'•.��pc.2`J,olgOp.{�.L f i$pMt
p10y?-,0�^.�t0-42trydACap��?0
TTM
I:.MFilM 6 IU.AL:.CL�/ 6�'•lE. ,6 r,+ b "\ItJV �"'F.B�+" MVN Z/� bee. Aii
- '
101
3 0y -000-4k9-0002
511ROW M(Y; IO)4 Ft, I . XM ID '101-000-241-000 S 0 3 P
ORADMO M, 101-000-423-000 $70.00
Dgif RWPER IMPACT WK SUVA
M*"AS4PLAIN' sdti i�gt9 fes:-3�.s lti0,t}f�
M�
ID e - a�a . ;3 i`tf�� trt:x�c� a r� car
:X ' o x'.104" � � e.
$3,584.4z
4250.00
AUG 15 2001e�11.?AffrIMDM Now
u :�
CITY OF LA GUINTA
FINANCE DEPT.
:a'
��y
RECEIPT
DATE r _ p
DAT IN
INSPECTOR
a•
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
b! I `
%`% �f
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
jog— 16. p ( 5'7
Exhaust Fans
' O.K. to Wrapl0
• _ d (
F.A.U.
Framing
AV .. /. o 57
Compressor
Insulation
—0i 5-7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
>E LNC. A✓W L' a to - GL S%
Final
Final
_ _
=� U -
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 67PWO/
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
�j/�1
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
(�
Temp. Power Pole
7•t
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
p Z -
Utility Notice (Perm)
_
�� __
P.O. BOX 1504
Building _ 78-495 CALLE TAMPICO
Address 511-620 Al/!' A-IjR /0 LA OUINTA, CALIFORNIA 92253
4 17 UC'LOpiar t/r- L L G
Mailing
Address yU -,9yf' J�'/`f�1/1%�f�i'E� Cr.
City Zip Tel.
Contractor
Address
Zip
State Lic.I City
& Classif. Lic. #
Designer 1W. WAS -IF
ress Tel.
�30Y 11274 __311_
Zip State
1-10 5, 2 ZSR" Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herebyy affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division B usi esss and Professions Code, and my license is:in ul) force and
effect. � /O
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5, Business and Professions Code: Any city or county which requires a
permit to construct, after, 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 ($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 l 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 contractors) licensed pursuant to the Contractor's License Law.)
17 1 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
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars (S100) valuation
or less.) . If
I certify that in the performance 9f Ahv worklor'A!hich this permit is issued, I shall not
employ any person in any manner s as to bea66me subject to the Workers' Compensation
Laws ,o,f C,a�lifo�r t�a�.
Date�Owner /,
NOTICV TO APPLICANT: If, afterfgIaking 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
ddress
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.
1 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.
•-V.�r>,
s
�� '
APPLICATION ONL A a-^- 5
BUILDING: TYPE'C..ONN.ST. CrCC. GRP.
A.P. Number
Legal Description
Description
Ft. r� No. No. Dw.
/p %S Stories Units
New q1" Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure_
[�A��]M OU NT
Z ] `i
REMARKS 3
f l3
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
FINAL DATE
Side Setback from Froperty Line
INSOECTOR
Issued by: Date Permit
Validated by:
Signature of a0plicant Date
Mailing Address Validation:
City, State, Zip '
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVI&ON
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 8/6/01 APN # . t 74-292-004
No. 22359 Jurisdiction La Quinta
owner NameSanta Rosa Development LLC Permit #0105-036
No. 54-820 Street Avenida Rubio #
city La Quinta Zip 92253 Study Area
Tract # B278U25 Lot # 21 Square Footage 1875
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 the amount of '
2.05 X 1,875 or $ 3,843.75 the property listed -above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may. now �e issued
Fees Paid By CC / 1 st Bank - Vince.D'ambra TelepXone
Name on the check t �'
By Dr. Doris Wilson
Superintendent
Fee collected /exe ted by Annette Barlow Payment Received $3,843.75
ll� wl Check No.. 59158
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) 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 aeother 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. REpjjB UC TITLE CO.
RECORDING REQUESTED BY
AND WHEN RECORDED MAIL TO:
Vincent Dambra
40847 Sandpiper Court
Palm Desert, CA 92260
DOC N 2000-346771
09/05/2000 08:00A Fee:26.00
Page 1 of 1 Doc T Tax Paid
Recorded in Official Records
County of Riverside
Gary L. Orso
Assessor, Countv Clerk 8 ReesrA—
r-
11111111111111111111111
1111.
1111
AF misc.
A
LONG
REFUND
NCHG
A.P.N.: 774Y9200 1 005 0 TRA #: X17 t0,(rOrder No.: Escrow No.: 2-31661
GRANT DEED Z
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY 82.50
[ X,] computed on full value of property conveyed, or
[ ] computed on full value less value of liens or encumbrances..remaining at time of sale, ��
[ ] unincorporated area; [ X ] City of La Quinta , and
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged, '
Harriett Linda Majane; a Widow
hereby GRANT(S) to Vincent J. Dambra, a Married Man as his sole and separate property
the following described property in the City of La Quinta, County of Riverside State of California;
L`W19 20 and 21 in Block 278. of Santa Carmelita at Vale La Quinta Unit No. 25 in the Cit of La
City Quinta, County
of Riverside, as.per map recorded in Book 19, Page(s) 50 and 51, of Maps in the Office of the County Recorder of
said County.
Harriett,Linda Majane
Document Date: July 13, 2000
STATE OF CRNIA )SS
COU TY OFA /dPP_91b-e )
On e4 OOe> before ,me,
personally appeared (Z tAJA,N. e
etscuraJ7j�innw^ �e_me (or proved to me on the basis of satisfactory -evidence) to be the persons) whose name(&)!i�ubs•-,ribed to the within instrument
and acknowledged to me that 1 he * executed the same in his hed ieir authorized capacity (ies}and that by 1 ' her signature(s)' on the instrument
the person(. -4 -or the entity upon behalf of which the person(s)"dcted, executed the instrument.
WITNESS my hand and\qLfici se
Signature
t This area for official notirial seal
icro•' L. GaLLE ps
' �" COMM #122786 .
NOTARY PUBLIC • CALIFORNIA
RIVERQpE COUNTrn
Y
m My Comm: ;xp. July 2, 2003
Mail Tax Statements to: SAME'AS ABOVE or Address Noted Belov^
M
RC DISTRICT - PLANNING REVIEW FORAI •
. r
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 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 Santa Rosa Developers
SITE ADDRESS 54-820 Avenida Rubio
APN 774 _ 292 _ 004 BIN NO'.: CASE NO.: 20+01-407
LEGAL: LOT BLOCK UNIT S.C.@V.L.Q.
CHECKED BY: Fred Baker- . 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
COMMUNITY DEVELOPMENT D
BY 3, ��I
Consistent with MDG'on file (as.applicable
' '
IL
A
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:.
Colors
Materials
Architecture
EX
i
IB
Other Requirements:
J
CITY OF LA QUINTA SUB -CONTRACTOR LIST L \
JOB ADDRESS - " �40 ?9y?AJ9/0 "i Oi LRMIT NUMBER _ _ OWNER �n6q '�C.�i. ��e/c rn�i�/L BUILDER 5 u� 13 L4 (dtC &04
This form shall be posted on the iob with the Building Inspection Card at all tim c in a con picuous lace. Only persons appearing on this list or their employees are authorized `'
on this )ob. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each aDDlicable trade- all infnrmatinn ranitactorl h911^%A1 .,..,.• ti_ ----1 ___.[__
I-
Trade / Classification
Contractor
Company Name
State
Classification
(e.g. A. B, C-8)
UV
Contractor's License
License Number
(xxxxxx)
%,V1111„V«U
Exp. Date
(xx/xx/xx)
Uy 0PP11L;dnr. vn He- Is
not an acceptable response.
Workers Comensaiion
Carrier Name
(e.g. State Fund, CalComp)
Insurance
City Business
License
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
Ixx/xx/xxl
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I-
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: 54-820 AVENIDA RUBIO
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0105-036
Occupancy Group: R-3, U-1 Type of Construction: VN Land Use Zone: RC`
Owner of Building: SANTA ROSA DEVELOPMENT LLC Address: 40-847 SANDPIPER COURT
City: PALM DESERT CA 92260
By: KIRK KIRKLAND
Date: JANUARY '15, 2002
Building Official
POST IN A CONSPICUOUS PLACE