0110-155 (SFD)-r' LICENSED CONTRACTOR DECLARATION *'
I hereby affirm under penalty of perjury that'I am licensed under provisions of
Chapter 9 (commencing with Section 70000! of -Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
-License # • Lic. Class Exp. Date,
70031 B C6 1042 1183E �tia
Date'- /E Signature of Contractor
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.
( 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 19t`!"13 �y 'Policy No. 1y
(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 p ov ions.
Date: �' �- Applicant— r
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, indemnity
& 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.
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.
Signature (Owner/Agent)–°% Date�C'
BUILDING .PERMIT _ "' PERMIT#
G
DATE VALUATION" LOT TRACT
197,2M.70 19 • 13 236; V22.
JOB SITE
ADDRESS 5+5^&{�ryAyK=.& r1
APN I' '
174-•a62-006
OWNER
CONTRACTOR/DESIGNER/ENGINEER
>fMM C'
Imm c- , , aw, ;TP-
330911"IC? ILPI C 1 t
1:��31Z01��1D1Ji�tA? rC S 25
PAIN: DEVERT CA 92260
PALM DESERT CA x+2261 •
(760)837.1566 C$1 ' :4905
USE OF PERMIT
01M F'.8J0M;Y DWYKI��.�iRi•Ci
SXPD .• WT 19 ( NUN ADA, SANTA F Z) PF. RMUT VOKS NOT I!..WC1,U D.lZ
:4L,OCK.WAi.1.,S, POOLIS;is'.A, OR DfUV9'WAY APPROACH
TRACT CONSTRUCTION .,6044.00 SF
i
PORCH/PATIO 103.00 SF
kAftl�C1FlC .PORT 4•lt�,00 (,T
ESOMA3E D COQ Oki' C011TI MU ON
97,2091.70
C(INST1R.F. C TICIN FEL 101 -ON -418'•000 �30,ia
PLAN CHECK FEE 101-000-4.R9-318
FSE DEPOtIrf 101.000-439-318 Si9S.Q0
MECHANICALF!i�L+'• :101-COON,421-01:10
141 fPWTRiCAL Mas. '101.000-420.M $113,56
r- AiNBRI30 FEE 101-000-419-000 $130.00
SP1o0.1.11 i MOTION FE - RASID 101-000.•241.000 $9.74,
;
MADAM ME 101-.000-423-000 M.D0.
DEVE3,sMM bar RAC k' HE 111007.00
i ,
PRYxi ? PLAN "' 101 ..4,00-441...1.1.3 $1100.00
S1: B-MITAL COWS'-AXY-110H AND PT_AN' C*'%_°K
$3,513.73
tLr 9 Pt.E^;PAXD'r
t�
i i,.. i
-$250.000
s ;' �'.Q'9:A.T., V 10ME YKES DUE NOW
ry�l�� } �r•
APR 1 o
V 1
RECEIPT
DATEBY
"':
DTEFINALED
INSPECT
INSPECTION RECORD
- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�38
Underground Ducts
Forms &Footings
Ducts
Slab Grade
Return Air
Steel
--Roof Deck
/_
���-L� �,�_
Combustion Air
Exhaust Fans
O.K. to Wrap
_ _
(7 •5 .p Z
F.A.U.
Framing
Insulation�i�-
�_'y.oz ��-
Compressor .
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
I Party Wall Firewall
Exterior Lath
Drywall - Int..Lath v Z—
j Final
_
v'lG
Final
POOLS.- SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
t Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
'•
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas
Final
Electric
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
Encapsulation
Gas Piping
Gas Test
s Appliances
I
Final
COMMENTS:
I
Final
Utility Notice
i (Gas)
"- ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
j Low Voltage Wiring
Fixtures
j Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
FinallG
OP
Utility Notice (Perm)����.
Building
Address
Owner
Mailing
Address .I
r1UW,,_ Z1p
f
Contractor ' )
Address l
I) !,' /.
�4M1 iZC Z P.O. BOX 1504
78-495 CALLE TAMPICO
7i_4A QUINTA, CALIFORNIA 92253
Tel
3)-1566
City 91� Zip r Tel..
State Lic. r City
& Classif. Lic. #,/'
} �.
Arch., Engr.,
Designer
sem' j
Address Tel.
/li' ; �`' � F i� :. �� �_ . 'c..s;.� ..Yip• - �' . ,'��-
City ! J ,y State
)r, -+ A, ! ]Zip/'.
/, 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 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 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)
1-11 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, 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
doesnot 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.--! ' _r] -Company I
(l Copy is filed with the city. ❑ Certified copyyis hereby fuinished:•
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, alter 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
Ihereby 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 aliplicant Date
Mailing Address
City, State, Zip .
UILDING: TYPE'CONST. I�
r
.P. Number 7/74-1
egal
,4-
egal DescriptionC
roject Description
Sq. Ft. No.
Size Storil
,�..: ts�•�•_ieWry, 7i!(mr_tF:l+tl��'iX'7Kq?+,�s�*3'�"`,.,r.�g�
APPLI ATION ONLY
i e OCC. GRP. O
iiiWk
r El
No. Dw.
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
k
I
itimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const. T
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
AMOUNT
n
II Intl
TOTAL p
REMARKS s t
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
r ,
^F DesertSandTs Unified School District.
,. 4
47 950,�DunePalms`Road
Notice:J:, ,�;1.��
La Qumta,fCA 92253,
Document Cannot Be Du ligated. r
p 7.40 2771'' 8515 ; 4
CERTIFICATE -OF COMPLIANCE
}.. r ter.
Date 4/10/02. u k APN # '774-162-006
No. 23124 'r Jurisdiction ' La Quinta
• ��.
James Belknap 155
Owner,I4 e t a ,; Permit # 0110-.
No. 53840 street `Avenida Ramirez i; ` ,
• ,, Log#
city La. Quinta Zip 92253• Study Area
Tract # SLK236U22Lot # 19'; V Square Footage' 1.604
r °t
Type of Developmept SingleTamily Residence �', No. of Units 1
- b -
4, :q, � • z
,. Comment's ract Coristriictiori of New• Single Family' -Dwelling of 16043sq. ft `
At the present tune; the Desert "Sarids3 Un fied tSchool. Disjhct ,does not' collect" fes on garages/carports, covered
patios/walkways, reslden'tial additions under�500 square feet; 'detached,acce'ssory structures or -.replacement mobilehomes. It
has been determined the above' -named owneuis exempt`trom?paying schooLfees ;at'this time due' to the"following reason:
: EXEMPTIONNOT APPLICA�BTE
This certifies that school facility fees unposed pursuarit to' ', Government Code 53080 in the amount of
2.14 X 1,604;. or -3 3,432 56' ti,, _ the property listed above and that building
V
permits and/or Certificates of Occupancy fbi this square footage, in this proposed projectmay,.now be issued
Fees Paid By James Belknap: Telephone 760/837-1566
Name on th6vheck
...By Dr. Doris Wilson :X r
Superintendent,
Fee collected /exempted byDlystahS,cott. ' Payment Received ' $3,432.56
a,
Check No.. 3,03826/cash
Signature s
- - .:#�; r �t+.. +' '�: r ,fir "' ,.'1•` a. rt .
�. NOTICE: Pursuant to Assembly Bill 3081 (CHAP 549 STATS 1996) ttii's will serve to not fy you4hat the 90 -day approval penod in which you may protest the fees or other payment identified
above %m begin to run from the date.on which the building br installation permit for'thisiprofect:is sssued oron which theyare paid. to ttie Districts) or to another public entity authorized to
collect them on the Distri&tCs)(s)behalf,' idh&erisearlier:_'
Collector: Attach acopy of county or city plan check application form ao district copy, for all -waivers.
Embossed• Original- Building,Dept./Applicant` Copy - Applicant/keceipt Copy Accounting
€ '.
01/11/01 12:67 PAX 909.890,3610 FIDELITY TITLE
Zz
Q002/002
n
RZ0 FS040 MQUUM By
AM WNW RECMZD MAM TO:
]amiss C. *811'a&apI '�Pji. Tm2ice
32 Camin Arroyo PLue
Palm Digi, CA 92260
A.P.N.: 774-104
0/0061005, )RA'#:
6jP:O4#2 I ff
Copy-, at Wit,
dhp�0'61. . bob . limnowwft
n A
UK.'L JQ"M
SPM Abon This Lim far Retwder's.Um 0*
..3300=5 Escrow No.: 2-322
GRANTT DEED
ME IiNDERM
X -I compared on, Pery coud-or,
,' Mesa=-vaZtte
of He= or e=Umbranc" remdaiLiing at time of sale,
uaiata7eporatedarAA1
tW�. "LO%A %IIAWY of La Q140ta Md.
FOR A VALUABLE. C ONSMERAIION; Receipt of Which is. h crebyadtiow1cdged,
Julian F. Fdagold, Trustee of, Us Sukvjvorls That -Old VMi* Trot, UA dated May 31, 1978
befeby GRANT(S) to JaMeS C. Bdknap, Jr., Tutee
of The J=es C. DeOmp Sep mu ThW, daud bl" 9, JM
the fbilowing deamibed property in the City of La Quanta, County of Riverside State of California;
19 and'40
CooneyIr
7lic Survivor's That =derFeingold Family Tnut, UA dated May 31, 1978
By:
JMn P. Pdlnjold7li_stee
D x a mcut Date: r 28.2QW
STATE OF CALIPORNIA - * M
on V" brFos mc; s06al�
PMUOW Wpared
ginve
zs
'ry' ki)'W be ft p=
-W Me Ouft. of Ci . Wa
and adMowk -1 —.1 1 - , , M* i"a MW� to so Wilhin huft=Pt
dge4 tD me that kddod'b 1ho =M in, an dkV MWM=t
d pvgsano�w ft _W fixemlbd
WnN= uw h=W xW offWd "
S'
IMs um for uffickl.noarld =L'�
WOEIff L SMAGM
=21
Mail Tax Statements
to: SAME AS 'ABOVE or Address Noted Below
RC DISTRICT PLANNING REVIEW 'FORM
This form is to be used by CD.0staffjot review of. single :family dwellings in the RC (Cove
Residential): District per=;Section 9.50:09.0 of;the Zoning .Code. ' Its purpose is to determine:
1) that the proposed, house; design does not duplicate the same architectural style of any
house within -200 feet of th-e appl c -ant, -and/or .2) if'�there is a need for`: the -applicant to file for
Master
Master Design Guidelines. If,_the.applicant doers need.to fire a`Master Design Guideline, please
transmitted this information to the'Build ing:and Safety,,epartment as part of your correction
list. Please attach addition al:�expfanatiohsi,as necessary. -
APPLICANT Belknap Construction,,
SITE ADDRESS 53-840 Avenida`, Ramirez
APN 774 - 162 - 006. CASE, NO.: 2001-557
LEGAL: LOT 19 BLOCK 23.6 UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY: Michele Rambo. . DATE: It p
Inform the .assigned Building plan checker.upon your assignment to this case. The CDD
Executive Secretary maintains a logbook to -track applications and assign case numbers.
REQUIRED' ITEM
;;Y,
N
COMMENT/CORRECTION
Verify legal and APN.information
X;
.
Consistent with MDG on file.las
J�
applicable
MDG filing required (5 filings since
T'
9/3/98)
Architectural variety within 200 feet of
��1E0 8 paZE
the surrounding area:
Colors :
S:
Materials,
CASE W'
Architectural design'features
pC
Other:Requirements:,
I
Certificate of Occupancy
City of La Q -1 -Minta
Buildin_a and Safety Department
_c[a tion in9 of-th' .•[lnifnrm>.Bui/dina► Code.
nf:%
iasis UUTI-l"Gidle /JSuvu wui,auacia, w .uiv •�y.....�..... ... ..�... _ _ - -
certifying ttiat, -at the time'of issuance, this atructure..Was in °comp/iance with the various ordinances
of the' City _regulating bud/ding- construction or" use. For the fo/%:wing:.
BUILDING ADDRESS: 53-840 AVEN:IQA. RAMIREZ
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit. No.: 0110-156-
Occupancy .Group: R3 Type of Construction: VN Land Use Zone: RC
Owner of Building: JAMES C. BELKNAP
Building Official
Ron
Address:
73300 fID,DLENECK LN.
City:
PLAM.:DESERT
By:
KIRK KIRKLAND
Date: 08/19/02
POST IN A CONSPICUOUS, PLACE.
Ism