0101-234 (SFD)LICENSED CONTRACTOR DECLARATION
'J 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
44 5 -IN B
Date - a t + Signature of Contractor C r _x. j ,
r
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 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.
(,;,)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.
STATE PUNT, 129090.90
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sh II forthwith comply with those$rovisions.
Date: nT , �. APPlicant �. i �. t i ix . , ; -• ..�.».. -�-
MIM iFlu; Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. u
IMPORTANT Application is hereby made to the Director of Binding and Safety
for a permit subject to the conditions and restrictions At forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La.Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and voila if
work is not commenced within 180 days from date of issuance ofd ci
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
11
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property dor inspection purposes
Signature (Owner/Agent]'.'-1_) > Date.!X r- ff"d
BUILDING PERMIT PERMTt/
TRACT
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
f"ALI `I:C'.TMOM C,c NSTRCYC"IIKYR
1-I.NC1MC VJOER i CO•NS"'l.'RIX-113C'W
1719 3 TRCM7
171991..1 O.NT
9 (,X%*A hr1D1% CA 9204
011; OCl AIMME C°J',. 92054
(760)"aw-0069 C'Ellut 1�5
USE OFyyqq,PERMIT
A��} 5j yp�*y�q ��(�?
LS,LLY.OLE FdhlKfl�JX dJWY.f:4:JZt{.1.4
;31M a ,PZRANT ROES NCrr INCLUDE, DL.DCL WAL.L4 POOL OR. ,O1t V1Z`iwfi Y
APPROACH, (1Jt11�.,,�,, 2 Yt/lAXI'I°'IM PLAN)
TIZACY C0101RUCTION 1409,00 81;
C1tr,11Y.AU- JC: AR1,'ORT E i) 10,173.40
5 Vr, 't OOD IAF CE 21.10.00 LF,
V91A+',EA1> 01100' OF CyQ.I`iSr'7°RUCITON
I?KMrr FEE SUMMARY
C"l7Aii1'I'11.UC T ION FEE 101_000_,4 1;�=tI00 1;S10,t2f3
PL.A'41 C'i£9CK rlv-r 1011-000.4439-_418 It+l$i.x1
NSEC HANICAL PIE 101.000.421.0304
04120-0001`
Itz'L.1�::"t RIC'A1,. VIP 101-0004120-0001
1.11morklo ME# 101 -=)-419.000 $110.1
STRONO DACITION ME • RM1D 101-000-2x31-000 $E.94
(IR.3b1~i11' a T`f."It 101-000-42.4-000 $20.00
DVISA.OP22 IMPACT FLF, ;19907.00
Furclse PL,&W 101-000441-34.3 �1t10.Ov
FEV. 0011,031T 1 101-0003.439-318 -050,()V,woof,
"
@ =, I1i3.B-`i`Cr`1.`Af, CL'>�I'�J shut �i`iOM Ab D1 F31:1' C3 i 1
;C3,di 1 �t.SCi
AN 2 6 20u1 ims P.RE.P r) pmuq
4250.00
l'
RECEIPT
DATE
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 i
Return Air
Steel i
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
�..q/
F.A.U.
Framing
�, p'�z'
Compressor
Insulation
3 - Z • d ( S
Vents
Fireplace P.L. 1
Grills
Fireplace T.O. }
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3-- 2, '6
Drywall - Int. Lath i
1
Finall�o
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs 1
Electric Bond j
Footings
Main Drain j
Bond Beam ;
Approval to Cover
Equipment Location
I
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING
APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping }(
l
Plumbing Final
Plumbing Top Out I
Equipment Enclosure
Shower Pans i
O.K. for Finish Plaster
Sewer Lateral i
Pool Cover
Sewer Connection i
a
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
s
Final
Utility Notice (Gas)
1
ELECTRICAL
APPROVALS
Temp. Power Pole
- i 0-01
Underground Conduit
..
Rough Wiring
Low Voltage Wiring
Fixtures I
Main Service
Sub Panels
Exterior Receptacles
G.F.I. i
Smoke Detectors }
Temp. Use of Power
Final !
Utility Notice (Perm)
� 57
6t/ _
Building
Address_5 60 //'7/,/l:
Owner
s Is
Mailing
Address
City zip
Address
Iq pleez-se- -Sce-'I
T4. h
P.0 BOX l 504
7844� CALLEtAMPIC0 APPLIC N ONLY
?c ? LA. QUINTk,_9ALIFOANIk62M
P ,
BU . ILDING: TYPE'CONST.- OCC. GRP. 3Ys
A.P. Number 7. Liz
ITel.
6()65 Lpgal.Descriptioni��-
Projec'fDescriptign-
City Zip .1 el..
State Lic. C
& Classif. 3z/ 2- `5 3-Z .1 EPO
Arch., Engr.,
Designer -
Sq.. Ft.�a No. Dw.
"�,? No. -
Size . Stories .. . Units
New 0 Add 0 Alter 0 Repair 0 Demolition LJ
Address
Tel.
City
State
Lic..#
;V, LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under prcivlslons&f�chapisr 9 (commencing with Section
' of Division 3 of the Business and Professions ,a, andriy license is Injjull force and
effect.
SIGNATURF DATE
OWNER -BUILDER DECLA RATION>
Lic"ense Law 'for the following
Estimated'Valuation'
I hereby affirm that I am exemptfromthe Ci5ntractcirs
reason: fSec. 7031.5.Susiness and Professions Code: Any4 clly..Oi county which requires a
4 1
permit to construct, alter. Improve, demolish, or -'repair any''struCturO,!'Prior to:Its Issuance also.
requires the applicant for such permit to rile a signed statement.that he Is-41censed 'pursuant: to.'
V
PERMIT, AMOUNT
the provisions of the Contractor's License Law, Chapter 9%(cominencinj with Section, 7000J_Of-
Division 3 of the Business and Professions Code. or that.. he. is exempt therefrom,' and the basis
for the alleged exemption. .,Ani- violation of Section .70ql.5 by,fany, applicant for a permit
Plari'Chk.' Dep.
subjects the applicant to a civIlpenafty 61h6t more than five hundred dollars ($500).
Plan,Chk. Bal.
1, as owner of the property, or �y employees witt�.wages as their sole compensatlon, will
do -the work, and the structure is not intended or, offered for sale. (Sec. 7044,,Buisness'and
CbnSt.
Professions Code: The Contractor's License Law does not apply to -an owner *of property who
builds improves thereon and no does such 'work;hirnself or. through, his i bv�n employees.
of
- h.
MiC
provided that such linprovements'ire not Intended or-offered4or safe. ff.,hoi�ever, therbuildlng
or improvementis sold within one 'year of completion, the owner -builder will have the burden
ElktitiCal
of proving that he did not build or. Improve to? the purpose.of sale.)
,
fl1, as owner of the property, am exclusi'vely,'contracting with licensed contractors*to con-
Plumbing
Sir I the project, (Sec. 7044, Business and Proteisions; Coos: rThe Contractor's License Law
uc c
improves thereon, who for
S.M.I.
does not apply to an owner of property. who builds or and contracts
such projects with a contractor(s) licensed pursuant to -the Contractor's License Law.) I
Grading
I. I am exempt under Sec. B. & P.C. for this reason
Driveway Eric.
•Infrastructure AM
Date Owner
WORKERS' COMPENSATION DECLARATION
JAIV
I hereby affirm that. I have atcertificate of consent to -self -insure, or a certificate of:
ALUU I
Worker's Compensation Insurance, or a certified copy. thereof."(Sec. 3800.Labor Code.)
0
Policy No. Companya
1-1 Copy is filed with the city. .0 Certified copy is hereby furnished.-
JIA r-)
TOTAL
CERTIFICATE OF EXEMPTION FROM
REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed 9 the permit is for one hundred dollars ($100) valuation
or less.) . I
iIil�c
I certify that in the performance h this permit ;is issued, I Shall not
f thg work. for wh this permitis issued, I Shall notempoy
any person in any manner so as to become subject to the Wdr.ktifs' Compensation
Laws of California.
Date_Owner
NOTICE TO APPLICANT: If, after making this, Certificate of Exemption you should become
ZONE: BY:
subject to the Workers' Compensation provisions -of the Labor Code, you must forthwith
minimum Setback Distances, -
comply with such provisions or this permit shall be deemed revoked.
Front Setback from Center Line
-Rear Setback -from Rear. Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
Iher by affirm that there is a construction Is . nding agency for the performance of the
work for which this permit is issued. (Sec. 3097. Civil Code.)
Side Setback from Property Line
Lenile(s Name
Lender's Address.,
FINAL DATE INSPECTOR
This is a building permit when - properly.filled out, signed and yalldated,and is subject to
expiration it work thereunder is suspended for 180 days..
.
I certify that I he ve read this application and state th;fthe above information Is confect.
-Issued by: DatePermit
'
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.
Validated by:
Signature of 30plican Date
Mailing Address
Validation:
city, State., Zip
WHITE =FINANCE YELLOW APPLICANT PINK = BUILDING•DIVIISION
7
Notice:
Document Cannot Be Duplicated
Date 1/26/01
Desert Sands Unified School'',District
47-950 Dune -. Palm. s Road
L,a Quints, CA'92253
760-771-8515
CERTIFICATE OF COMPLIANCE
N
APN # . 773-626-001
No. 21574 Jurisdiction La Quinta
Owner NamePacific Trades ,Construction . Permit # 0101-234
No. 52-260 Street Avenida Ramirez Dog #
City La Quinta Zip 92253 Siudy Area
Tract # BLK82U10 Lot # 22 Square Footage 1409
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 1,409 or $ 2,888.45 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 - Temecula Valley Bank - David: Miller TelOphone '760-967-0069
Name on.the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow Payment Received $2,888.45
/ Check No. 14598
Signature
N0710E: Pursuant of Assembly Bill 3081. (CHAP 549, STATS. 1996) this will. serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the data on which the building or installation permit for this�projecl is issued or on which. they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
Dec -18-2000 11:40am From -COMMONWEALTH LAND TITLE +7603413215 T-816 P.001/001 F-939
RECORDING REQPI STEp''`>9Y:
CHIC AGO. TITLE'COM..PANY COMPANY
10618KC 2o7�0s8276 w,.iar.�• -' -
„WHEN, RBCORDED.;•MAILc THIs DZED •AND, ) '
UM49SS OTHERWISE' SHOWN,B$L&' .d
MAIL TAX" STATMdCXTS' TO:.
DAVID ROSS .MILLER `
1719 S_ TREMONT
S. OCEANSIDE,- CA'9025g'
SPACE AaOV8,THTS LI R -RECORDER'S USE
AP110 77;4-114-015 773-262-001
. - ... �GRANT.•DEED� - . - . .
The undersigned grantor($) declared
• . Docume"ntary- transfer tax is :550.6.0 ,
(XXX) Comput ed on 'full value oft property conveyed, or ;' @N. `�.a�t ►[�Z.,
( );,Coiciputed.'on full. value..;less 1'rens :and encumbrances .remaining 'at rime of sale.
y ( ) Unincorporated area. 6( ) Ccy of and
'
FOR A VALUABLE CONSIDERATION,.recept of:.whi.cn is''hereby acknowledged,
'ROBERT F. EDINERT and ELISE. J. EBBERT, `husband and wife a= joint". GenanLe
.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 '22, Bloc):. 82'., Unit No. 10, Tract Santa- Carme•lita ;at Vale., La Quihra, , as per map
recorded in 1n Book `18-, Page _ (sj 7o inclusive--bf- maps,, iii rhe office',.of 'the County Recorder
of said'Counr-y_
and Lot 5,• Block 189 "Unit No. 10, ,Santa,,,Carmel}r_'a at Vale La°Quint'a, as per map
recorded' iii° Book':19, Pages" -33 -34 -of- Maps , ° records of Riverside Co_ unty,
DatadcrntaemDer'15, 2000
State of-Califoi:nia
County of }' S _ S._ ROBERT.:F ' nEBBERT
On
before me, 4
personally appeared ELISE J_' EBBERT
personally xno4ih to me.. (or- proved_ to . me on
X
the basis .of .sar_isfAcr_ory-evidePce): to be
the person(s) whose nameA.s') .,is/are subscribed
to the within instrument and.=acknowledged to',
me char he/she%they.executed the same,in,
his/her/their authorized capacity(ies), And
that by:his/her/therr._signacure(s.I:'on the
instrument the person(s)`,' or the '',entity'upon
behalf of which the `person (s)',acted,e-execuied'
the instrument'.'.
WITNESS my hdi4'aind official seal._
Signature ..(This area for official notarial seal)
MAIL TAX STATnJ1:NTS TO:
`• Lid - - T • ...
O P
13C
NC
Initi
C
.` yy
-1 - PLANNING REVIEW FORM:
RC,:D.ISTR
This form is to be used,by CDD:staff'for review o`f'single farriily dwelling's in•the;RC (Cove Residential)
District, in order to determine the'applicabrlity:'of-compatibility issues,k,.need to requite: the filing of Master
Design Guidelines by the,cappli6ant '�It..sliall be transmitted to the;$uilding andfSafety`Department as your
correction list: Please attach additional explanations, as'necessary.
APPLICANT PACIFIC `TRADES'
` d
.SITE ADDRESS 52-=260 •Avenida"Ramirez'
APN
773 _ 262 _•t • 0 O l;e; BIN INO.: w- CASE NO.: 200-1-385
LEGAL: LOT 2 2.BLOCK 8:? '` UNLT S.C.@V.L.Q.
CHECKED BY: Wally.. Nesbit;. 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'assigri case,numbers:
REQUIRED ITEM ' "
N
COMMENUCORRECTION
Compatibility Review
�%.
,,,/A '
Case logged,and number assigned
Verify legal and APN information
Awi-/C44iV '<' /%4 /7 /Loll nr♦tLiC
as applicable"
Consistent with MDGon-file (as.
fi •).
MDG filing}required (5 filings since 9/3/98);
,
Consistency with street%sunoundmg aiea:
Colors
7
iv
ti� Materials
''
4
Architecture:
�h
Other Requirements:
dvLl'`? :ou-•��cs�r,� v/o �ss,,«z
u5� c�w�ss� r•r�,/,�, .a,2
oVed by: Date Resp
anning Commission
#
ty Council
mmunity.Dev. Dept.
7 . sv
Is
as �;.
Exhibit '
O With Conditions'
T
2
Certificate of Occupancy
City,ofLa.Uinta 4
� z - ,
Bu ld ri r -and Safet -De artment :OF
g
, y p
This Certificate issued pursuant, to. the. requirements of Section =.Z09' of- the. -Uniform:: Bui/ding, Code;
certifying that,'at the time of issuance, this structure`'Wag in comp/lance wi h the orarious ordinances.,
of the 'City regulating b ding construction or use: _For the fo/%wing:
BUILDING ADDR'E.SS: - 52-260 AVENfDAOm. IR;EZ
Use Classification' SFD ' - Bldg. Permit'No... 01-01-234 .
Occupancy Group: R, 3 . Type` of Construction: VN Land Use Zone: RC
Owner of Building:, PACIFIC TRADES CONSTRUCTION ` Address: 1719 S -TREMONT -•
City: S OCEANSIDE; CA 192054
By: STEVE:TRAXEL
Date:- 05-04-01
Building Official
POST IN A CONSPICUOUS PLACE