0207-039 (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. `
�'lite License L]]ic.C[ lass Exp. Dante
jDate rqq rr�� ,pp&gnature of Contractor ,
f
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.
,K) 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:
Carver STATV, liiTgD Policy No. 1340864
(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: 4' .... L4. Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to'the conditions -and` restrictions set forth on his'
application. •
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify '
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from 'date of issuance of such
permit, or cessation of work for 180 days will subject,permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree.to comply with all City, and State laws relating to the building
construction, and., hereby authorize representatives of this City to enter upon .'
the above-mentioned property for inspection purposes.
/Signature (Owner/Agent) - f ,� Date
J BUILDING PERMIT PERMIy�
DATE VALUATION LOT TRACT
X611.4,28 'dAO 113
JOB SITE
APN
ADDRESS,-4..dn�.�r'a�
OWNER
CONTRACTOR/DESIGNER/EN (NEER
C114911 "Ir`IT: G WANG
1 S LTa, G �Y a
23S0 BLY)EHANTEW DIM
D014 (.^§ PIRACE CA 90803
R'0VV1.AKD.HFV3-B.U. CA 91748
(626)z74•7548 FIJI
USE OF PERMIT
MI-�1•+�O7 �' q e"( �r y-� ♦,yrL
Z
,�
,
q4(`�L7LC�l�.�-� yic°L.L1�{i,'�Yy� y'ytp { � � [� � / y / to (� 1 r [.� p� } 1
�$g.' t�+�
f6.1FI) n t_lt'° 3, PERMIT DbFS' N0 1iRM,t.rt D,,,? SLOCK VIALLA P VLF.f.� a:d'�A,
i iV4' VI9IJCTIOM TO Pi:IMV C�'MCK FEE IX i0
IS'S'Ii14NCP Of SAME PL.l4 N 'I`SI°PR
TRAC #' CONSTRUCTIONI,�I6,N OF
IAR.lt 06CARPO.R+�T436,00 Sly
5 I¢ % WOOD YTOICE =001 ly
F9 FWf I4rXf .' 6U.i's!CMM;kY
COMMUC1,'10N FEE 101-00011-418-000 MUD
LAN CHW2:1:T K 101-000-•439-218 $143.54
MI!:MM IC.',a L YZF 101-000-4,211-000 $42.59
Pi.tlFiliiN10 FES 1 g1 rCtC)i) 1 A�I1fbi) X3.39, ;
S'i'RONO iilt;3'fIO fl'u!`T 371"p51i3 1X1'1-000-241-000 $111.43
4 t 3�tt3E REE 101-000.423.000 U10100
DEV.EI OP1?'•T.. IMPACT YZE $1,mo
FES Df"'P09I'P
1y �
AAT],+VI(
?.�(1)ra}�1�.531f
'h{�df_-;;.T-i�'�:�::
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RECEIPT
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
..W
14,
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
'Set Backs
Underground Ducts
•Forms & Footings
—,/.3
Ducts
Slab Grade
— 3 —3
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 Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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
Waste Lines s
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
6 ��-� �S
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole Z —�
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:
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J
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
584434 B HIC 01/31/2(
Date 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
1, 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 STATE FUND Policy No. 1360864
(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
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.
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
BUILDING PERMIT PERMT#
0207-039
TRACT
DATE VALUATION $114,284.40 LOT 13
JOB SITE
ADDRESS 78-635 SAGEBRUSH
APN 646-311-013
OWNER
CONTRACTOR / DESIGNER / EN (NEER
KATHRYN .L=
CHING KUNG WANG
6215 SEVILLE COURT
2380 BLUEHAVEN DRIVE
LONG BEACH CA 90803
ROWLAND HEIGHTS CA 91748
(626)274-7548 CBL#
USE OF PERMIT
SINGLE FAMILY DWELLING
SFD - LOT 13, PERMIT DOES NOT INCLUDE BLOCK WALLS, POOL, SPA
OR DRIVEWAY APPROACH, 75% REDUCTION TO PLAN CHECK FEE DUE TO
ISSUANCE OF SAME PLAN TYPE
TRACT CONSTRUCTION 1,916.00 SF
GARAGE/CARPORT 436.00 SF
5 FT. WOOD FENCE 200.00 LF
ESTIldATED COST OF CONSTRUCTION
114,284.40
PF RAT T FEE S'UhD4ARY
CONSTRUCTION FEE 101-000-418-000 $692.00
PLAN CHECK FEE 101-000-439-318 $142.54
MECHANICAL FEE 101-000-421-000 $42.50
ELECTRICAL FEE 101-000-420-000 $124.28
PLUMBING FEE 101-000-419-000 $134.75
STRONO MOTION FEE - RESID 101-000-241-000 $11.43
GRADING FEE 101-000-423-000 $20.00
DEVELOPER IMPACT FEE $1,907.00
FEE DEPOSIT 101.000-439.318 4250.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$3,074.50
LESS PRE -PAID FEES
-$250.00
TOTAL PERMU FEES DUE NOW
$2,82.4.50
RECEIPT
DATE
y
DATE FINALED
INSPECTOR
v�}t' T9ii""'� � T. . �' tY?`t'r:'•; •1 �.i+r -:�n 'i'�," r""t�a'vF�'�*" : r y '-ur -,.f �,,"�gc' � :f, F"a(dfi�b4�i!�f'R%'"'.$ jF'`�'�''y�
.F .� Adaffui
P.O. BOX 1504
Buildingxxb�5 5�Ec GF 78-495 CALLE TAMPICO
Addresi p LA QUINTA, CALIFORNIA 92253
Owner
Mailing _ _
Address? ./ , �!'� t t= f 1
City , Zip /! Tel.
)AI(7
Contractor
OL,/"',r' Z /.,(-/I DTrl�
Address
State Lic. City
& Classif. I Lic. #
Address Tel.
City r Zip State
/JA 11 /L/r./% C4 %17r: 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
fessions Code, and my license is in full force and
effect. ___/1
SIGNATURE / IDATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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).
L., I, as oner 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 1 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.)
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
r7 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100) 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, 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
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 ,slate that the above information is correct.
I agree to comply with all city and county ordihances 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 applicant Date
Mailing Address
City, State, Zip
e
0
APPLICATION ONLY
-�/ 0
LDING: TYPE'CONST. /1 OCC. GRP.
Number 54 -el, — J; �1 � / 3 (O 7-
al Description _/,–,7
ject Description % ✓r1i.S._' s �t rr ir_�� G?t<t ll �.v
ZONE:
BY:
Minimum Setback Distances:
r
Sq. Ft.
Size
No. No. Dw.
Stories Units
!
New ❑ Add;❑
Alter ❑ Repair ❑
Demolition ❑
Side Street Setback erom Center Line
Side Setback from Plloperty Line
Fq
FINAL DATE
INSPECTOR
Issued by:
Date Permit
/
Validated by:
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
a p
e"
d
TOTAL '`
1 %
AM
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from R3ar Prop. Line
Side Street Setback erom Center Line
Side Setback from Plloperty Line
FINAL DATE
INSPECTOR
Issued by:
Date Permit
/
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISIDN
CERTIFICATE OF COMPLIANCE �F>�sc
Desert Sands Unified School District z°�ca�o
47950 Dune Palms Road ¢ BERMUDA DUNES r
Date 9/27/02 - La QUlnta CA 92253
RANCHO MIRAGE d
� C C • � INDIAN WELLS ti
LM DESERT
No. 23664 (760) 771-851 rJ ��nF LA QUINTA y
0
,
Owner Kathryn Mitts APN # 646-31-1-013
Address 78635 Sagebrush Jurisdiction La Quirrta
City La Quinta Zip 92253 Permit # 0207-039
Tract # Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 13 78635 Sagebrush 1916 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments one check pays for cert 23663 and 23664 plus .48 cash
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/wdkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating o sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq. '
in the amount of $2.14 X 1,916 S.F. or $4,100.24 have been paid for 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 Far East National Bank - Eddy Tsai Check No. 165910
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Crystal Scott $4,100.24 0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 isseed, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
y
MAR -07-02 THU 05:21 Pit
? 8. (0,3 S.6,BSIA
r—
DOC
R^ RO 200®-3!!>tiinil�
ECORDING neautetao OT Q N/f7/2SOe Oa:eW Fp:Zp,N
Paye 1 of L
�• �- Raaardad In Orftelal "*Cards
county of Rlv*rslde
A NUW I t IN nICUt+t IF U MIat tWc!11 FO ANOUNIASS Wry L. Ora*
UUtt I UdU S+IU'NN(J1U;W NIA4:A XSIA I E MLN. I U R*sa***r, County Clark It R***rdar
- Y.nthryn 1: :itis -- 1IN11111111111111111.111111111
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dA2/S sel/G/L/,- H is
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A It l fo.• ,Ora al,uq aC.O tu.,
i '1'?tiS is a bnnoffje P1 !t an•i thn erimtcrs rA,!# ver'
GRANT DEED ° r T
THE UNCERSIGNEO GRANTOR(s) CECfARElsj Ll
,.
DOCUMENTARY TRANSFER TAX is
U computed on full value of property conveyed. or
• ❑ computed on Full value less value of liens or encumbrances remaining at time of
Sale. and
FOR A VALUABLE CONSIOEPATjON. receipt of which is hereby acknowledged.
John MusicIn & Elizabeth A. Musiah, as trustees or the kusich Trust dtd
April ?it, 1934, hereby
hereby GRANT(Sj to
Kathryn I, butts, an unmarried woman
es hAr sole 4 aaparate nrceerty
the following described rgal property in the
Uunty of Riverside . State of California:
Lot 13 of Wit 61 of the Desert Club Panor, as per war) recorR®r? in Rocs: 2?,
Page 53 of mans, in tho ofFtce of the county recorder 041 n814 musty.
Assessor's Parcel Number 811381013-8
ti., ad �•�Cri_6,1489. - --
SLATE ur CAUFUftI_p_
COUN'IrOF __T% Ad8*lee
on Ma _ _'L �_ _ •---..... - .. _betore mw the
undersigned, a Notary Publ+ + eh tors d County ens Stele,
pereonalt a gonad 1*�in &uafcali
A'
yerunasy knTrn 'tc me
for A^ated to me on the Sarna ul ttauet*ctary evdennl to be the
psraan 9 *hose name 0 d" i)IVO "bad to the w+lh+n
.nelrumeM and aaknaa!edged thet t:Ioyo,fcwod the same
'hITN! 6S n+i lland end etLcsol seat
Lo, W.., x, -
ohn Munich _ Trustee
c 7 sbath HusicTk Trustee
WEND
Itotety
LOS MMLK
�I gandl� �. 3i)I 90l �
l7h,a ar*a for erdC+al nou,"o: se,!l
/64411 TAX I&TA`Tttea CATS Ali njame.ven AMO%Un
Description: Riverside,CA Doc=ent-Year.Doc1D 2000.359858 Pag®: i of i
Order: EDDY Comment:
YOUNG ENGINEERING SERVICES
Engineering Architecture•Surveying• Building & Safety Services
Letter of Transmittal
To: City of U Quinta Date: 5/6/02
Project: 78-635 Sagebrusi (2" check)
Attn:
Tel No.:
Greg Butler
W.O..
Tract No.:
1
We are forwarding: X By Messenger
No. of Copies
• 1 .
1
1
By Mail Your Pickup
Description:
Plans (2"d submittal)
Structural calculations (V submittal)
Structrual calculations (2 "d submittal)
Comments: Structural content is approvable.
This Material Sent for:
Your Files X Per Your Request
Your Review Approval
Checking At the request of:
Other
By: John W. Thompson
Phone # 760-342-9214
47-159 Youngs Lane, Indio, CA 92201 (760) 342-9214
Bronz Young
�- ,�'^'_'" te of Occupancy
, 0 0Certifica
INCOMIATM
�IgU
Building &. -Safety Dep' a rtment.
This Certificate is issued pursuant to the requirementsof Section '109 of the California Building
I
Code, certifying that, at the 'time .. of issuance, this structure was in compliance with the
provisions, of the Building Code and thid various, ordinances of the - City- regulating building
construction and/or use.
BUILDING ADDRESS:'78-635 SAGEBRUSH
`Use classification: S.F.D.- Building Permit.No.: 0212-176
Occupancy Group: R-3 Type of Construction: V -N Land Use Zone: R -L
4
Owner of Building:- KATHRYN MITTS Address:, 6215.SEVILLE COURT
City,.ST, ZIP: LONG BEACH CA. 90803
By: G. SHOWALTER,
Date: 01/27/04
`'Building Offidal'
POST IN A CONSPICUOUS PLACE
t -c