9807-171 (SFD)r LICENSED CONTRACTOR DECLARATION
a 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 mg License is in full force and effect. ,
License # Lic. Class Exp. Date
X125381 .$ � •� 7l3�'�f$
/ate f�
Signature of Contractors
g
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
contractorsto 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.
Se( )• I have and will maintain workers' compensation insurance, as required by
ction 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.
S'1'c•'>`VE i+UNL7 1-^f'a0`JSt)
(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
�jode, 1-s�all f rthwith comply , ith t ose p ovisions:
Date; �� �� Applicant—
Warning:
pplicant -
Warning: Failure to secure WorkersCompensation 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.
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. IIagree 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 inspectionpurposes. „
/,gna'ture (Owner/Agent) ��. Date
PERMIT# CONTROL#
BUILDING PERMIT
9801-17
DATE VALUATION LOT.. � d
TRACT7371 3 7
q C t
JOB SITE
ADDRESS 77^.� � dwl�1.l.�'r i?t +� �> �
APN 774-27.1-024
OWNER CONTRACTOR / DESIGNER / ENGINEER
DAWDR1:4S MILLER PAC1'I":C'TRAD' S CON.S;`IUC"TICYN
1719 S IREIVION11 1719 S °1`1-EMONT
S OCEMSIDF CA 92058 S 0CEANSIC 0E CA 92054
(760)967-0063 C -fl 1955
USE OF PERMIT
-SINGLE FAMILY 171dTLiANG
n.
+1✓D - IIF 13I.00K WALL tI-i I Li7D :t). PERMIT DOEI NOT INCLUDE
POOL g �
•1•%AC1' C��rs��:u:;'r1r�N' 1,6��.tw :;;:�
%'Gilts 1 il1'A f1q tti.1 sr'
Q1"1AGFJCAMPORT' 4751.00 S '
.
BLOCK WALL (HTILt%)• 174.00
6 f"r. WCiC?191:°rNcE 75.00 Lt;
• L'
(iys
h
� f
$/1$p. �1 $
C'i ���' C3r':s' 1�+'.8"Q 317✓'C�Q
p
201,573,40
t�q gam, g!�'�SyT.1.15:gt�:l.�i.ai
� s. SUMMARY
•� y7� g �+. FEE
C°C?N..31MUCTI 0IN FFX 161 -000 -419 -0tH) � � W,6.50
{
PLAn CMECK FJT, $547,29
NIECHAIQCALFE.IP 1101••000<421-000 '' $50.00
1C•1-10CaL-FETE 101-000 f120-000 $140.615
FL1JIVIB NG FEE : 101-000-41 fL000 $139.50
'411Z,fiNO A.40TION F1'F - Rf✓SM 101-000.141-000.
ti tAq„ 0 O:EE 101-000-423-000 $20.00
INFAA,STRUC'TtAU.'- Iy 225-000-443.342. $„256..35
;P1tEti1n` E PLAN 1.411-000-441.-345 $25.60
A:RT IN P't)E1f1.0 :PLA(ims, - 3tEsm.70! -I.7. )-255-00-10
FEE 1301:1031T : ; . 101=000-439-318 422).00
SL11='1Y t�E,GCI�iC 12C3f_`1'ltiz?.A! a'I. I�IGIIIAC+
-9,$49.35
LFSS �1 -PRII: FEES
'1<O �: L l[�1�'Rt'V IT 1+ E S OU'C NOS
3.:�!i9.3�J
RECEIPTDATE
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
b
Return Air
Steel
_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
—
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Latho
p �f
`•Q.i
Drywall - Int. Lath
Final
Final
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
Electric Final
Waste Lines
!�
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
y
Pool Cover
Sewer Connection
���7 �0
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
_
(Gas){
ELECTRICAL APPROVAL
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
t
Final
Otillly Notice (Perm)
_
�- 7
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 9/25/98 .
No. 17813 , Jurisdiction
Owner NameDavid Ross Miller
No. 77-310 Street Calle Potrero
APN # 774-271-024
La Quinta
Permit #
Log #
City La Quinta zip 92253 Study Area
Tract # Lot # Square Footage 1675
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.fo the following
reason: ei
b r
J �6 lT � I"•
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 1,675 or $ 3,232.75 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/Capital Bank of North County/David Miller
Name on the check
By Dr..Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre Payment Received
Check No.
Signature
I
Telephone (760) 967-0069
$3,232.75
055992
NOTICE: 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 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 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
JUL.15.1998 6: 52AM COMMONWEALTH
RIECORDIXG REQUESTS BY
OLD REPUBLIC TITLE COMkCOMPANY
98-7667KC 110737-13
Waw RECORDRD MAIL T8X9 DEED A=#
MMESS OTHERMSX SHOWN Bnow
HAIL TAX STATIMMS TO:
DAVID ROSS MILLER-'
F18CbNP6V0,N& 92054
NO. 396 P.2/2
.10 CA
SPACE ABOVE TUX9 LTHR PMR 1012flAimmota watr
GRANT DRED APNi 774-271-024
e un Ersigped �ut dec q6s);
g,r-ar, r s
Tar an ax Is
-ar
0M E! n va ue
on
aj8e D erty cmaedor
u e on va u? e3s ��Yens and en um rances remaining at time of ale.
nfflorporatR area. C1 of and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
WILLIAM THOMAS BUFFIN, AN UNMARRIED W
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 12, BLOCK 270, UNIT NO. 2 . 5, SANTA CARMELITA AT VALE LA QUINTA, As
PER MAP RECORDED IN BOOK 19, PAGE 50-51 OF MAPS, RECORDS OF RIVERSIDE
COUNTY. CALIFORNIA
Dated July 15, 1998
State of California
County of
on -
before —me.
personally appea-r—e-d
persona y, known to me or proved to.me on
he basislof satisfactory evidence) to be
theperson(s) whose name(s) is/are subscribed
to the within instrument and acknowledged to
me that he/she/they executed the same In
his/her/their authorized capacity(ies), and
that by his/her/their signature(s) on the
instrument the person(s), or the entity upon
behalf of which -the person(s) acted, executed
the.instrument,
WITNESS my hand and official seal,
Signature •
(This area for official notarial seal)
MAIL TAX STATEMENTS TO:,
CARLOS ELIAS
REGISTERED CIVIL ENGINEER
38825 Charlesworth Drive
Cathedral City, California 92234
Telephone (760) 328-7271
August 1.0, 1998
City of La'Quinta
Department of Building & Safety
78495 Calle Tampico
La Quinta, Calif. 92253
Gentlemen:
This letter concerns the residence to be constructed on Lot.
12, Block 270, Santa Carmelita Tract, La Quinta, California.
I have reviewed the layout and bearing points of the roof
trusses designed by Structural•Truss, Inc., and find that their
design is in conformance with my design intent.
Q�OFESS/p Yours very truly,
(0 /of
No. 16M Carlos Elias
CE: j
(PA CIVIL
9lF0f