0107-077 (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.
License # Lic. Class + Exp. Date
B MC
Date"I- Y i5. r'' ✓Signature -of Contractor �" „a•>' x'. A, y
-'^'•'------'- ---•"'OWNER-BUICDER"DECLARATIONco
�� •`'
U I hereby affirm under penalty of perjury that I am exempt from the Contractor'sP'
L License Law for the following reason: /°'--
( ) I, as owner of the property, or my employees with wages,.as their sole
rnmpansation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professiorials G608).
( ) 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
LO
N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
Z I hereby affirm under penalty of perjury one of the following declarations:
M () 1 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
J, JQ performance of the work for which this permit is issued.
I U ( ), I have and will maintain workers' compensation insurance, as required by
Q Section 3700 of the Labor_ Code, for the performance of the work for which -this
H permit is issued. My workers' compensation insurance carrier & policy no. are:
Ir Z Carrier Policy No.
3 Z) 1C;1t1KYX FUND
J(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply withithose provisions ,
-Date: . -7 r Applicant1r .O �? , ' !
.W.
Warning. Failure to secure Workers' Compensation•coveragews unlawful and.,-
shall subject an employer to criminal penalties and civil fines up to $1,00,000, in'r
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code interest.and attorney's fees.
A
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 of4his City to enter upon
the above-mentioned property for inspection /p6rpo�ses ;
r Signature (Owner/Agent) - Date
BUILDING PERMIT PERMTk
f.
DATE / VALUATION LOT 01,07-077 TRACT
_
15 DC1
JOB SITE
APN
ADDRESS
7"S.5 V&'1,GIM811610 Ari &
64 6-311-615
TOWNER
CONTRACTOR / DESIGNER / EN INEER ,
f' t�'".L,ARKE M+i�.�}a„E�PM
i:"Dis".:�.,MMIMPYS, INC.
P) BOX 450
,1-.200 AVINIDA Y3��LTD.N , 1_Y 2, RM
p.AkqU1AI'DP%. CA 92253
L,,t. Q'k!'1:NTA CA 92253
UTE OF PERMIT
APwi1OACy1;3(M:!'aS"t`ER•MAID)UD) 93 tr'ODO
TRACT 4 i-10TRUCT1_Q1? 11899.00 a?
fAr± RACI.N' 491.00 Sir'
K '1" FRIT SUMMRY
tNWS'37tU `1'10 1 FEE 10) -000,410.000 5685100
lNb,la1*3.C1; EC K FV* 1911-Q00.433-318 $57.#.613
kEEDEPOSb'1 �- .. 101000-439-319 VS0100
",,.�
1�1�"f: iAN.tCA1.�'PE 101_000-A27-000 $66.60
9
1! 1,,1;C.`TRICAL lei?da 101 -000-43.0"000 $124.79
i
kr'LWAFt'1:v9.3I'M s. E)1-!if:0-4.1y-Q
MON() MOTION RX - RRISM 101- 0.241.000
� 0.
0".xlrNO FEE 101 •D&VELOPER
IMPACT WE
r
110.0'?"S L C0; i"11T Akv?T.sD 1A.
. . 11•i•C,
CITY 1`�9 PRE.�a
F1NAN i ,I Our
RECEIPT
DATE BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _ _
Forms & Footings O
5 7
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck8
= ?jo—p (
Z_—r
Exhaust Fans
O.K. to Wrap
9 (
F.A.U.
Framing
C_ _0(
�"
Compressor
Insulation
_ _ ._p2
g'�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
iI-���
S%
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
'7 -j �- O t
�j7
Encapsulation
Gas Piping
Gas Test 2—
Appliances Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
OVALS.
ELECTRICAL 7_z?
Temp. Power Pole icl
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
1 Smoke Detectors
I Temp. Use of Power
C
Final u 0
Utility Notice (Perm) - -
v yrt�s-syt js °: &v S�'7 + `r'✓j 'kp". W� ' `
Via
P.O. BOX 1504
7
Building x < 78-495 CALLE TAMPICO
Address //%05�>G�2UjtJC'QUINTA, CALIFORNIA 92253
Owner
Mailing
Address O (�
City, Zip Tel.
Contractor
Address
City , Zip Tel.
State Lic. City
& Classif. Ts. Lic. # + G/
Arch., Engr., /
Designer
t_4 t
Address Tel.
City _ ,_h Zip State
v' . 7 F ��� 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 thathe 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).
t7 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 of sale.)
I'I 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.)
17 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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
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 it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thF 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: 9, 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 sof this city to enter the above.
mentioned property for inspection purposes.
Signature of aQplicant Date
Mailing Address
City, State, Zip
Q�z^�
APPLICATION ONLY
.DING: TYPE'COLNST. OCC. GRP.
Number t/' ` & _ 3/// ` 0/S
Description
Q
:t Description Z_,o= /.S �1' ESC727' Cc-��cg
Sq. Ft. j j; 7
Size_
New ❑v Add ❑
No. ' No. Dw.
Stories Units
Alter ❑ Repair ❑ Demolition ❑
;timated Valuation
.PERMIT AMOUNT
Plan Chk. Dep. ZSU
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback frcm Center Line
Rear Setback from Rear Prop. Line
1
Side Street Setback from Center Line
Side Setback from Prooerty Line
FINAL DA
Issued by:
Validated
Validation
WHITE = FINANCE YELLOW = APPLICANT
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 7/10/01 ,
�•• � APN# 646r311-015• �.
No. 22234 Jurisdiction • La Quints
Owner NameClarke Enterprise Permit # 0107-077
.41
No. 78-655 Street Sagebrush Ave. Log #.
City La Quinta Zip • 92253. Study Area
Tract,#. DC 1. Lot # 15 Square Footage 1899
Type of Development' Single Family Residence No. of units 'I
4 ' Comments Overpayment of $7.00. -
_ 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 to the f6_lowmg reason: ,
' EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in th? amount of
2.05 X 1,899 or $ 3,892.95 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/Union Bank of CA/Lendel Ventures, Inc.` ' `
T�.le�hone
Name on the check
By Dr. Doris Wilson ffill' r.
.t`
Superintendent .
Fee collected /exempted by Juanita Green Payment Received $3,999.95
Check No. .7531160
Signature ,
fNTICEPursuant Assembly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may prote-- the fees or other payment identified
e w1into nmthe date on which the building or installation permit for this project is sssued or on which they are paid to the Disbict(s) or toanother public entity authorized tolect them on the istrict('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
_t
1"M;REQUESTED BY:
u - h'Pe is ES
RE/MAX Real Estate Consultants/Escrow
Divisiol �w
AND WHEN RECORDED MAIL TO:
AND MAIL TAX STATEMENT TO:
Troy Clarke
Order No. 514720-1
Escrow No,01-00081-ST4
Parcel No. 6.46-311-016-6
SPACE -ABOVE THIS LINE FOR RECORDER'S USE
GRANT DEED
THE UNDERSIGNED GRANTORS) DECLARE(S) THAT DOCUMENTARY TRANSFER TAX IS $44.00 and CITY S
X computed on full value of property conveyed, or
computed on full value less liens or encumbrances remaining at the time of sale.
unincorporated area: La Quinta and
FORA VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Ward Howard and Cindy Howard, husband and wife as joint tenants
hereby GRANTS to Troy Edwin Clarke, a married man as hs' -sole and separate property
the fol lowing. described real property in the County of Riverside, State of California:
Lots 15, and 16 of Desert Club Manor Unit #1 on South side of street (Sagebrush Street) as per map recorded in Book 22,
Page 53 of Maps, in the office of the County Recorder of said County.
Date 3/16/01
Ward Howard
Cindy Howard
ss SA(I,& , N �
STATE OF CALIFORNIA
)S.S.
COUNTY OF (,, }
On 3 ' �"1 '� I before me, the undersigned, a Notary Public in and for said County and State, personally
appeared Ward Howard and Cindy Howard personally known to me. (or proved to me.on the basis of satisfactory
evidence) to be the person(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 u on behalf of which the persons) acted, executed the instrument.
WITNESS my hkncyand official, seal.
e emn:+vmc:cn•�bac�nnsi.
_Signature LX�.: YVONNE O'BRIEN
' Comm. 1253837
NOTARY PUBUC-CALIFORNIA
SANTA CRUZ COUNTY
{"
2aa'.r yN-1Y COMMISSION EXPIRES FEB 17 ZfA4
�:�tscavnmr� Axa
Certificate of Occupancy
City of La Quinta.-
Building
and Safety Department
This Certificate issued.pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 78-655 SAGEBRUSH AVE.
Use Classification: SFD Bldg. Permit No.: 0107-077
Occupancy Group: R-3, U-1 Type of Construction: VN Land Use Zone: RM
Owner of Building: CLARKE ENTERPRISE
Building Official
Address:
PO BOX 450
City:
LA QUINTA CA 92253
By:
KIRK KIRKLAND
Date:
4/23/02
POST IN A CONSPICUOUS PLACE
L
C"91QwwlQUlMA
Bwlft & S*ty DepL
Imo` STOP WORK ORDER
MiM 960) 777-7012 INSPECTOR