9906-035 (SFD)LICENSED CONTRACTOR DECLARATION
�. E I. hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
License'# Lic. Class Exp. Date
6P_ d LO 291728 Ii `� 08/31/2(M
LI J
rJ (�
oZ Oate :f �' ` Signature of Contractor .'�fc�e.-'- ' - --
U C:) OWNER -BUILDER DECLARATION
HLU r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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 Oroperty, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section , B&P.C. for this reason
LID
N Date Signature of Owner
ON
CA
Q WORKER'S COMPENSATION DECLARATION
C) Z Ir I hereby affirm under penalty of perjury one of the following declarations:
r H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X U compensation,, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U (19 I have and will maintain workers' compensation insurance, as required by
Q USection 3700 of the Labor Code, for the performance of the work for which this
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
cob O IrrATE PIJNU 229-99UNI U 31014130-'
Q (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
sub'ect to the workers' compensation provi"sins of Section 3700 of the Labor
Code, I shall forthwith comply with,those provision's.,
ea e: �/� Applicant
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 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.
46-1
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.
I certify that I have read this application and state that the above information is
• correct. Lagree 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)'%�"�'�`�-►�'' Date +0r17"i
I ' f
BUILDING PERMIT PERMIT991WO&W
DATE VALUATION $",163.20 LOT 4 TRACT 111,K232 U22
JOB SITE'
ADDRESS = `: i3 AV ,t�i1llA RE\N11.ki1(Z
APN 7 74-121-016
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA QU.(N'rA PAI".'R11 itS
WIIA,IAM RUSSELL It:OQERS
51-370 AVE NIDA 13URMUDAS ,
56.900 JACKSON
LA CSL MI -A CA 92213
THERMAL CA 92274
(7ti013951•• 1200 C81,4 1954
USE OF PERMIT
SNOUZ FAJ ILV DWELLINt;3,
3
SR) - F&RUT Wa1=S NOT f MMI_Wss LAL OCK WATA. OR .POOL.
17RACT CON37MUMON 1.605-00 'OF
POI( ;t11'A'1'10 930) 31;
GA1{r4QrJ, C;fU0A.AkT 46.3.(X) SF
5 Fr. ' W0OD FFI IN H 2t.N.►,ttt111
ESTIMATED COST OF MINTSTRi;4,."ZION
!w.1.63.m
i PRIM[' FEE,, SiiMAJARY
C0.Pl8TRUr.: r fQN FEE 1131 -OW -4184M St3i�. Sti
Vf.1A_N TIV( 1K1111 i!/n�1.r�H(1�±�,.,az-3(t�Rry �y� ix
A15:1I1`A�?i ICIUs!'1i 7V 'ilttV^ L1^i�1lW J�)(10i
fill :.I RICAL F -0i
t'i.UA1,1iIN(} FEL 101.OW-419-000
MCY4'[f?A1I.M.-RESID 101.11(!(!-241-()0t►
GR.AL)Pik; Ili s 101-000-42.1.000 $21}.110
:(lvi ltt1.�T12tJC'lCJ1t(i ►�i? 22.5-M-44-1-342$2 lri5.i
HtECIN PLAN 101-000-44t-345 S,"ti.t►t1
F17110)"10191111 1Ot-()(.'i(1-419-313-S2�t).iNi
SLtF.; IrI11:AK. CONS") t1 IX'PON ANT) MAN C''HFCK
$3,7')710
1.13'SS PR.1:-PPE) f'EFS
42S7.00
'fo i'A!'., 3'.e§:.itM IT 1+'US 01 IE NOW
$3,477.30
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
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
70 - QQ -
F.A.U.
Framing
r/'. (—
Compressor
Insulation
y_ T Y
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_/76 ti
Drywall - Int. Lath
Final
Final
�� rt'Y
POOLS -SPAS
BLOCKWALL
APPROVALS
Steel
Set BacksElectric
Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
7- - S-7
Encapsulation
Gas Piping
Gas Test
y q t S
Appliances
Final
COMMENTS:
,
Final
Utility Notice (Gas) / fq
ELECTRICAL APPROVALS
Temp. Power Pole (o
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) m!
LWT
Building
5-3--5(05Address AV
T4`v1 4
P.O. BOX 1504 APPLICATION ONL
r 78-495 CALLE TAMPICO
2A 4 t f I GIA QUINTA, CALIFORNIA 92253
Owner
Pailin
Address P *!,7a
City Zip Tel.
linlifll �'J Z S 364
VVllll a�.rVi J w /�- C I
4 ! �l'(%0
1q. /_Z-oo
State Lic. I City
& Classif. C(( ZJ1, Lic.
Arch., Engr., `
Designer
Address ° I Tel.
City e� -) 90f r✓ I Z� 6 21 -T-3I Lic.t# I
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 rile 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 or 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] 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 or sale.)
I'I I, asowner 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.)
1-1 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. O 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 ($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: It, atter 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 for inspection purposes.
Signature of atfplicant Date
Mailing, Address
City, State, Zip
BUILDING: TYPE'CON/S`T. OCC. GRP.
A.P. Number&%1i
Legal Description � � 401 Aim,
Project Description �� �% 16Za6/1_ Z (,IZZ—
Sq. Ft. No.
Size Storif
No. Dw.
New1u, Add ❑ Alter ❑ Repair ❑ Demolition ❑
L
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const-
-Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
I
TOTAL
REMARKS
{) AMOUNT
ZONE: BY:
Minimum Setback Distances:
Front Setback from enter Line
Rear Setbackknfrom Rear Prop. Line
Side Street Setback from Center Line ,
Side Setback from Property Line
FINAL DATE
-INSPECTOR
Issued by:
Date P19-
1iValidated
Validatedby:
Validation:
1
Esq` N
TY F LA
TA
I
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVIWON
t
Desert Sands Unified School District
'47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 6/9/99 APN # . 74-121-016
No. 18872 Jurisdiction La Quinta
Owner NameLa Quinta Partners Pernit #
.No. 53-565 Street AvendiaRamiez Lag.#
City La Quinta zip 92253 Study Area
Tract # BLK232U22 Lot # 4 Square Footage 4,605
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 gara„es/carports, covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or repla-:ement 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 m.tAke amount Uf ,
1.93 'X 1,605 or $ 3,097.65 the property listed above and thaftuildiug y�
• permits and/or Certificates of Occupancy for this square footage in this proposed project mzy'. novP be ssuEd'T
Fees Paid By ccNIB/Tom Buffin
Telephone-`x399'•1200 �1
Name on the check
i
By Dr. Doris Wilsona
Superintendent
Fee collected /exempted by Juanita Green Payment Received $3,098.00
Check No. 1951'05
Signature
NOTICE: Pursuant of ssembly 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 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 mother 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 wai-ers.
Embossed Original- Building Dept./Applicant Copy'- Applicant/Receipt Copy - Accounting
May • 25. 1999 1:50M :POWER BROKERS No. r:220 P. 2
..:ORDING S12009STED 8Yc
r:??CAC0 TITLE, COMPApK COMPANY
v:.A6N8Kl 970;5914
w3: zX 12001402b MAIL TWIS . aria An
UNLRIS OTHSAMISR - SNOfM RXLow,
MAIL TAX STAT*gws To, J
"":•LIAM R. RILEY. iRUSTEE
P.O. oOX 2121 I
DI..'X DESERT, CA 92261
- -0 •nia &ARM POLI �C �IA
GRANT DEED APx: 77¢-121-015-4/774.
Tr -W. ca c. -ell'
V;2 undersigned grantortai declare(e)..
Durumeneery traneYa'r tax is 9
QVXXI Computed on lull value or pro
pptrey conveyed, ee
Computed on ll value lees limns and ancumbrancee remaining at .time of .sale,
i ) Unineorporated area, (or1 city OL c.A N
and
rc,,t A VALUASLE .CONS.IOERATION,-Reeiot-of whlcli is hereby ecknorledgod,
r'r/ uETTG AMBROSE H�,p, III and VINCENT -HEALY, JR..
CaT_it 19 t0 an undivided )./: int,Tre&c
hereby GRANT(S) to
tv;:,LIAM R. RIZAY, TRUSTER OF THE WILLIAM A. RILBY 1990 TAUST
the rail property in the Cit
as�: y of LA QUINTA.. County of Rivaraid*. Stag Of California,
de:.criDed
Lw: ra) 3 and 4 fn Block 232 of Santa, Tract Carmelite at Vale Le Quints, Unit 22;, as
Re -.:order of pr:.rnop recorded in 20, Page(a) 2Q ineluoiva of maps, in.th• office of ehi County
,said County.
Dz;-ad April 9, 1999
'St,.%:e of t;aliturnia
i:C:::hty of _fI r•' y S.S.
b(.-: •.)r4 me, _ / i 6 _ / •/1 i r .". • v
• ,.r peroanallyappeared
Ps"10nplly known to ma (or proved to ma on
chs.. basis. of eata„fgccory uvidfnce) to be
till parI�ol(vt whose ndemgte) tflore subaeribed
tc the withir) inAtrutnent and acknowledged to
me char Aalmhe/they prvcutcd the acme in
.1'4y/i:mr/their avthnt;32sd ¢aDlatylie0), and
rn.: by his./Iw.r/thetr nignurure(a) on the
In.—%rumont rho (>,rir.p}t{Lf, or tilt. unticy upon
beli.,ll or whxCh chP pereon(u), acted.. executed
-ft" lnutrurnsk.
W -:.MESS my halo ant) otf.ciol X08L.
�, ,_I
MAIL TAX 5TA?tgaN79 roc
VAMY, AS A)N)VN.
TV
MARQUET'iZ AMBROSE H_EALy, III
ViNCENT HEALY. Jit;
i`
ECM L ka
' I
(This area for offleial. net,rrlo: seals
n