0203-103 (SFD)•'•Cn
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed undeFprovisions 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
Date ignature of Contractor ^.�A
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 isnot intended or offered fore
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. j
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 S'3'A7'F' FUND Policy No. 1360864
r .
(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: ` s' _ Applicantt ! r
Warning: Failure to secure Workers' Compensation coverage is unlavlful 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
fora permit subject to the 'conditions and restrictions set forth on his
application.
1. Each person bpon 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)' t, Date
' PERMIT PERMIT#
--BUILDING (12ww.+03
DATE ` -` VALUATION e1.yy..pp� 2�p8(49.1 .,0�y LOT An TRACT
'�/ dDAl�yana'•�r`fiB fro
47JOB
SITE
ADDRESS +ici w 1`
APN .6,16'311-01.4
OWNER
CONTRACTOR / DESIGNER / EN INEER
J011 k1C°1at1�►
1'21'5 N. 811D '.Y PL/kC'1..- ,
2310 RLUEETAV1411 DRIVTt
AMAVISRk r::'A 9170.1
RC.iVArL&'t`iX3MUGMM CA 91748
USE UE HERMIT
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SY D • L(Yr 14. PEWIT 1 02S ;td.OT INC;IX13F 1':ig.00K 1isALL % P001, UPA.
OR, 1:)lafM:MA
YAPP111.0dkay,
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TkA..C't` CONS'1'K'UC'flCyil`1 1p1s op sp '
tS OW.Ci;1��I:.ilrt.7:Y ' 436.00 S?
5 FL WC OD.. M. 4CE 200.00 LY
19f-7Zdii{R@ XJD.D COSSIf OF Ci.r83!(}:iMivd.R.O
114K280ao40
C'O NSi'RUCY ION FEI. 10.1.000418-000 S492.00
PL.AAW CHECK kF':_ '1011.00 .d 9-2"18 $5711.16
N1&CH AINTICAL:M '101.040,421-0GO Wb35D
E11'.,�aECTq)I'ICAL.,��?tER 1�!01=•(G�09-, 4.`1.0-gC�00� $t24 9
]J,UAfi1}1 o P.• a 101 -0'0 0-4' i,e i0db �1'Vt. 4i.5
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S'dRiSYtG1lRC1°I`it12�i T+1 ., 7'v 'i?P 101-000-241-000 $12.d3
X11 .ANG FUZ 101-000-423-000 bi�,t�t1
I)EV'ELPR1,11 JIMPACT P22• 1,9tb7 Otb
FRE 1AP0.131°f
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�5'i3't3-!"�i F1."t t:C3k� bRLfC_"f 74t f ,Y�i1 i �,5�► .G$mpjCr£
$3 502.12 -
Y)rAL
RECEIPT
DATE
BY
DATE F/INALED
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
0. 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
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
(6 3 -�� S
Encapsulation
Gas Piping
Gas Test
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:
�.1 " `" , r i,_1X ,J = IFY 4Z.,.. r r 1 ; ,.."J� . .,. ,. „I...A..., •rR�-r,-�,,.�-;�,... •}1'�W>'� iv57+Ct Ri'f= �r.�;l+i s LTA
10�
2
0 W
lJ P.O. BOX 1504
BuildingBG� LA LTAMPIO
Address QUINTA, CALIFORNIA
92253
Owner
Mailing
Address
City _ , - _ I Zip Tel_
ress
Tel.
State Lic./ I City
& Classif. / Lic. #
7
��� { I 0 7 5- Z
Designer 9J' 6
Address Tel.
City" (Zip ��'r3'y (State
—, N
I A //; 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 thealleged 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 (5500).
C-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 'hat he did not build or improve for the purpose of sale.)
I'1 I, as owner of the property, am exclusivelycontracting 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.)
I'] I am exempt under Sec. B. & P.C. for this reason
T
Date Owner_.. �;�
n
1
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate g
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.J I
Policy No. Company
F7 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 permil 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, 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 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 a0plicant Date
Mailing Address
City, State, Zip
fg*n° -
APPLICATION ONLY�6
BUILDING: TYPE•CONST._ OCC. GRP.
14
A.P. Number 6�i �3,.8..�s°
Legal Description ��/�' C!/f"�, LL-s�z7►'G'�+t6FA7L.
Project Descriptionfor
a
Sq. Ft.
Size
Add ❑
Valuation
PERMIT
Plan Chk. Dep
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
D.r-iyeway Enc.
No. No. Dw.
Stories Units
Alter ❑ Repair ❑ Demolition ❑
ZONE: BY:
Minimum Setback Distances:
Front Setback fron Center Line
Rear Setback frorr Rear Prop. Line
Side Street Setbacfk from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
1 �
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIWSION
MAR -07-02 THU 05:26 PM FAX N0.
RII:coRolefo REQuaurRo by 0 DOC 0 7000—MI58607
I,
e0/13/2100e *4:00 fa:29.N
t - s.ti. f of I
' Raaorded !n 0f11e1*1 Ree* -ds
AND vIWtN t 1LEXPOEU NAIL —;5 C -E f r. ANO UNLESS County of Rlvu.lde
11".ItuW4gt%;"UWN111t0W VAq TAV rTATrtArNTTO Gy t.
RgtQlea►, County Clerk b Recorder
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__-.-_ . • A l 00/r I.a.Y , WJO .Y O VAW
Tit to Lona `i as a: `t a the 9r!ntcr< race vet'
no. nv `�n return, T 4f9��,
GRANT DEED I
THE UNDERSIGNED GRANTOR(s) DECLARE(r4 e1G
DOCUMENTARY TRANSFER TAX Is $'
O Computed on full value of property conveyed• or
computed on full value less value of hens or encumbrances remaining at time of
sale. and
FOR A VALUABLF- CONSIOC-RA710N. receipt of which is hereby acknowledged.
John '!'Is! ch & Elizsbeth A. 'dusich, as trustees of the '!usich Trust
dtd April 21), 1981,
hereby GRANT(S) to
Johr• Charles Yusfch, a sinple man
the following described real property in the
County of Riverside . State of Callfoenis:
Lot lit of Unit ii of the Desert Club Manor, as der Yutn rocorded in Book 24,
Paye 53 of MPS, in the office of the cotanty Recorder of said countq,
Assessor's Pepcel Number 6173 81 014-9
rmta,tKMM _ .5,2984
............. --
S1ArE UP CALIFORNIA
COUNTY OF !!oS I T SS
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OFrICIAL SEAL
WENDY A. ANDRE
Notary PUbft-Cala-ft
LOS ANfttt r Ooij y
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Description: R-411a'r1ide,CA Document-Yaar.DOCID 2000.359887 Page: I of I
�xder: EDDY Ccrcnent:
KI
YOUNG ENGINEERING SERVICES
Engineering Architecture•Surveying• Building & Safety Services
Letter of Transmittal
To: City of La Quinta Date: 5/6/02
Project: 78-635 Sagebru.ch (2" check)
Attn: Greg Butler W.O.
Tel No.: Tract No.:
We are forwarding; X By Messenger By Mail Your Pickup
No. of Copies Description:
1 'Plans (2°d submittal)
1 Structural calculations (1St submittal)
1 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