9904-103 (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
628404 t3 � 07,'3tll7i
Dte %� 5 Signature of Contractor
= OWNER -BUILDER DECLARATION
Si•hereby affirm under penalty of perjury that I am exempt from the Contractor's
F 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.
ST111't'T1. F11'N" 3 15-412304
(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 those provisions.':_--
Date: Applicant
V1,. .
Warning: 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.
IMPORTANT Application is hereby made to the Director of Building and Safetyw
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
o 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
1
�Slgnature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
"t14»103
DATE W/VALUATION �iH����3.�tt LOT TRACT iia ll t IN
JOB SITE
APN
ADDRESS ?3-205 AVI.ltit10r11 %1AtlYliD(RE
773-051-021
OWNER -
CONTRACTOR / DESIGNER / ENGINEER
PtTNk N110Ut TALI i REAL ES"t`AM INIC
Ct`.;.t�t?I�*7[r�.l?,s'SE�'•T t::�Pl rTRLC".t7(�,1`�'
713170 A119BEIt S'T
'.3170 Ahl�asti 5i'.ttFt"I'
I'ALM C3FSI' RT CA 32200
PALM DESE;.ft'I' CA 92260
(769)340.9844 t'81 A dROt
USE OF PERMIT
SF D - iETWIT DOES NOT INCLUDE Bl.�Ck K WALLS OR POOL
TRACT CONS'rRUCTION 1,448.00 St:
F" ORCN/1"Nr at 15,00 iii
0AI{AO&CARPOR'[' 430.00 St,
b FT. WOOD FENCE 2fiU,06 LF
'a"i,%4*Tit;D CXAS T Of COINS `INIX- ION
38,'153.90
PERMJT FEC SIINIMARV
C0NS'F'li.tX:F10N FEE 101- UU-418-000 SS90.00
PC A.N Irl"ECK Ftl! $49 .42
AXCt•IANiCA), T r t01-0001 21-0130 $60.00
a Lt CTIUCAL F H.E iqt-a00 Shu-0i7D $128.78
'PLUMBING Fffi 101-000-419000 $1'W 1.50
gf9tM�T?OF
GRADING FLM 10t-00042-1-00 :5.^,0.00
tNFR.A�tTROC,'TCrFtEFF.E 22rl}t?0-443 � #2 $058.72
PRECISE KAN 101 -OW -441-345 525.00
FIR 01.1110119 T' � 1011-0(P4- 4-:1 t tx _8250,00
a
C ONI'tVU(MON ANT) t► AN (7ifFC. 'rS'.
TOTAA., VERMIT VE*r;S 01) C NOW
53,162.32
RECEIPT
DATE
BY t4
DATE FINALED
INSPECTOR
N
t r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Z
Return Air
Steel
Combustion Air
Roof Deck
((—
Exhaust Fans
O.K. to Wrap
. ( — 9, Y Tsy
F.A.U.
Framing
(_ Q 7
Compressor
Insulation
_ Z—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Will Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lathox
Final
Final
BLOCKWALL APP OVALS
POOLS - SPAS
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
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
r (
Encapsulation
Gas Piping
Gas Test
— f
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
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:
p
P.O. BOX 1504
Building �S' 3 205- �.(] a /� 78-495 CALLCALIFORNIATAMPIO
Address' /7 T[ Lr LA QUINTA, IORNIA 92253
Owner ,,-% " • ,t 1 Z—)
Mailing `7711 A e
Address31
C��i77ty Zi / TI
Contractor
Address
4
City IZip ITel.
State Lic.r. I City
& Classif. Lic. #
Arch., Engr., '
Designer
Address I Tel.
City IZip I State
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 Contractors License Law for the following
reason: (Sec. 7011,5,8usiness 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 of not more than five hundred dollars ($500).
1-1 1, 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, Bulsness 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
�proving that he did not build or improve for the purpose of sale.)
�,,oyLf
�' 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.)
i7 1 am exempt under Sec. B. & P.C. for this reason
¢ Date -' Owner
Y
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 fjC
WORKERS' COMPENSATION INSURANCE J
(This section need not be completed if the permit is for one hundred dollars ($100) valuation)
or less.)
1 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 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 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 -of this city to enter the above-
mentioned property Tor (`nspectiompurposes.
Signature of applicant —Date—
Mailing
ateMailing Address _
City, State, Zip
l�
APPLICATION O LY "0 4 -i d 3
BUILDING: TYPE'CONST. OCC. GRP. /
A.P. Number 7 7 4—OSY— V 'A, / PA*.2z&00 Legal Description LoT /ii nctc �,�0. �fYl'! PA* .2 Z &00
Project Description AGo S I b eAriA/ r't o w e
Sq. Ft. !�
Size 7
NewV
J p No. No. Dw.
1 b Stories Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
on
PERMIT.'
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
9
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback -Tom Center Line
Side Setback from Property Line
s
FINAL DATE INSREbTOR
Issued by: Date Permit
Validated by: DA I in
�N � 4n0
Validation:
MAR 17
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION /I'i T OF LA V N
TAa
Notice:
Document Cannot Be Duplicated
Date 5/3/99
No. 18665
Desert Sands Unified School District
47-950 Dune'Palms Road'
La Quinta, CA 92253
760-771=8515
CERTIFICATE OF COMPLIANCE
Owner NamePine Mountain Real Estate, Inc.
Jurisdiction
APN # 774-051-021
La Quinta
Permit #
No, 53-205 Street Ave. Ramirez Lo; #.
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 1448
Type of Development Single Family Residence 1`-o. of Units
Comments
r
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 replamment 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 th-, amount of
4
1.93 X 1,448 or $ 2,794.64 the property listed above and that br ilding
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid B CC/Union Bank of CA - Doug Peters
By g Telephone"5689729,,,,=
. .
tr,
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Ellen Patino Payment Received ,$274.64-"'
Check No. 6527539
Signature C1�C
IOTICE: 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 ft fees or other payment identified
bove 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 ano4her public entity authorized to
oltect 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
RECORDING REQUESTED BY:
AND WHEN RECORDEO, .MAIL TO:
California Desert Construction
73170 Amber St.
Palm Desert, CA 92260
ASSESSOR'S PARCEL NO.: 774-051-021
TITLE ORDER NO.: 120064-13
ESCROW iso.: 4902 -DS
GRANT DEED
THIS SPACE FOR RECORDER'S U:E ONLY
The undersigned Grantor(s) declare that the DOCUMENT TRANSFEF
TAX IS:
$ 12.65 County $ City
xx computed on the full value of th 3 interest of property conveyed, or
computed on the full value less 'khe value of liens or encumbrance:
remaining thereon at the time of sale.
OR transfer is EXEMPT from tax for the following reason:
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Marian Alice Decker, Administrator
hereby GRANT(S) to PINE NoXiNTAIN REAL ESTATE INC. , a California cor-poration
all that real property situated in the City of La Quinta County of Riverside, State of Calitornia, described as:
Lot 10 of Block 220, Santa Carmelita Vale at La Quinta Unit No. 21, as shown by map on file in Book 20, page 22 of
maps.
Dated February 24, 1999
STATE OF CALIFQRNIA,
COUNTY OF _
• iii `� - �
Notary Public, pers�onally appeared /
personally known to me (or pro ed to me on the basis of satisfactory evidence)
to be the person whose name is/0 subscribed to the within instrument and
acknowledged to me that she/ executed the same in 0/herltWir
authorized capacity(g, and that by Kher/00 signature) on the instrument
the person, or the entity upon behalf of which the personacted, executed
the Instrument.
WITNESS my hand nd official seal.
Signature v�
Marian Alice Decker, Administrator
A, A AL A &
THERESA A. WILSON
COMM. #11W939
oanaoa 001^17Y
r+r e�•ie► &0" ,Al) 34, goon
MAIL TAX STATEMENTS TO: (This area for official notary seal)
California Desert Construction - 73170 Amber St., Palm Desert, CA 92260
CERTIFIED TO BE A TRUE AND r'RUE AND
CORRECT COPY OF THE ORIGINAL �;�- YI-IE ORIGINAL
}
RC District - P/anmi q 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 or 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: CALIFORNIA DESERT CONSTRUCTION
PROJECT
ADDRESS: 53-205 Avenida Ramirez
APN: 774-051-021
-__LEGAL: _LOT 10 ,.BLOCK 220 UNIT 21 S.C. @ V.L.Q.
C K' D BY: FRED BAKER
BIN NO: See Building CASE N0. 99-50 CHECK 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.
II REQUIRED ITEM I Y I N I COMMENT/CORRECTION 11
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) !j
r
Consistency -with -street -/surrounding -area: j
Colors J
7 I
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.
Certificate of - .
Occupancy Od
City..of LaQuinta
►YOU+uifD ��.
BuildingSafety and 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 incompliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 53-205 •AVENIDA RAMERIZ
Use Classification: SFD Bldg. Permit No.: .9904-103
Occupancy Group: R 3 • Type of Construction: VN Land Use Zone: RC
Owner of Building: PINE MOUNTAIN REAL ESTATE Address: 73-170 AMBER ST.
City:. PALM DESERT, CA 92260 -
By: STEVE TRAXEL
Y Date: 12-21-99
Building Official
POST IN A CONSPICUOUS PLACE