9612-116 (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
ti 1!?t►fit} {3 if 3 } A)
"Date 2-1 g Signature of Contractor
iJ
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 Policy.No.
STATH FUND .12tj7-996.96
(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
s Nect to the workers' compensation provisions of ection 3700 of the Labor
Aode, I shall forthwith comply with �� provisio ,
Date: 1 ` '� Applican
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
/thabove mentioned property for inspection/purposes.
nature (Owner/Agegt) �� --• �-f `� Date
BUILDING PERMIT PERM T# °°NTR°`#
9612-116 4623
DATE I12.1/97 VALUATION S97.602.80 LOT TRACT
JOB SITE
ADDRESS 78-725 SAGEBRUSH
OWNER
CONTRACTOR/DESIGNER/ENGINEER
30.01 IN CARPER
APOLLOS c oN5':1' ucriON
79140'010_1rI LLO
79te1L ocar).LL O
LAtiL INFA. ('A 92253
LA QU.TN'1'A CA 92.75;A
(699)3610-4335 ('.13L# 22231
USE OF PERMIT
53;4)
117-D-Plit.Qt IT 1. Eo NOT 1NCLUUE' 81.d:iCK WALL OR POOL.
1'K.la1,.: r CX.)1d:tiiTC3.:iCTION 1.604.00 SF
tx �ft� 'ti/t'rt'i'IU 1.�10.ljEl 3F
�;AFtAtr Jc +t.)3'�'1 441.(R) Sr
Ct `�T M1,N'i'Z:3D CMT Or" CONSTRUCTION
97,602.80
yy,,,gS ���� pp'
ff pp� ddyy yf FEF,
7.AB.l..R M1 t� 1`i,L' F, Jf{).1'�"l!.'id.-AR R•
f:' _)Ni8'€ RLlC 1 I0N .t• F', 101-(3WL4 i 8,W0 5630.50
PLAN 01FC ' FEE, $51_g.61
€>LA.N til E-0" WOSi'1'
ivi1:: MA:NICAL FEE'S 1021.000-4.21-000 $53.30
EL1ii;TIRICAL "FES 101-000.420-0110 5128.46
1'I.U"ONG RTS 101-00014114-000. $15'1. ^5
.
.TIM ING t,10TION OWN) 101 -0€* -241-000 39.116
GRADING E 01-U(!t)-42:s-0011 xn..00
f°N1:RASs'tJ(.Ttf lH' 2-25-000-443.342 `2,154.17
Afd,EC-13P. PLAN 101-000-441-345 525,00
PAM;'x' I'A!, f'C:fiV`1' I i(JION AND PLAN (�HFC�K.
AM
$3,714.25
LESS Pt'IF-M- D FEES
$250.00
AN 21 1997 11►cRmh' FU FNoMr,. WAIN
$3,464.25
CITY OF LA QUINTA
RECEIPT
DATE
eY "
1.1
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Y
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fire lace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
`
Final
Final
POOLS - SPAS
BLOCKWAL
A PROVALS
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
f
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICW.44ROVALS
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)
Desert Sands Unified School District
Notice: 82-879. Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 1/16/97
No. 15184
Owner Name John Carper
N0.78725
City La Quinta
Tract #
Street Sagebrush
Lot #
Type of Development Single Family Residence
Comments
APN # 646-311-022
Jurisdiction La Quinta
zip 92253
Permit #
Log #
Study Area 123
Square Footage 1604
No. of Units 1
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 following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.84 X 1,604 or $ 2,951.36 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 oc/Hemet Federal Savings/Apollos Construction - Telephone
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson
Signature 1, D1 A I 01 'u atv_��
r—
Payment Received $2,951.36
Check No. 989290842
OTICE: 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
bove 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
ollect 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
Rt.Coltl)lNt; REQ!. k-51 t:.0 BY
AND WI IGN 11,1"C'01WED D "L TO:
Jolru L. Carper
2750 Bay Village Circic #2071
.-� Santa Rosa, CA 95403
FIDELITY NATAMAL TITLE INSURANCE CO.
A..P.N.: 646.311.022 TRA #: 020042
PAID
Doc. Iranety ` IX
FRANK K JOHNSON.
Rhe.. Co. Fteoorder
RECFJVEL) FOR RECORD
AT SIN OrMOCK
NOV 2 91995
rjoc rd.o inboat r dwao
er wtt.niUr�.c�en:a
A000cdeX
Feei $_
Space Abow This lane for Recorders U,,c Only
Order No.: 261259 Escrow No.: 2022.05
GRANT DEED
TIAL: UNDERSIONED GRAWOR(c) DRCLARl;(,)'t'l►A*r IS: COUJv'1"Y L1t .45_'!
X j computed on full value of ,pro erty conveyed, or
computed on full value less v&e of liens or encumbrances rcinaining at time of sale,
.ullincorporaled area; ( X I City (if La Quinta , and
l"OR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged,
Lee Allen Woolf I1, it single. titan
Iihereby GRANT(S) to John L. Carpe., an unmarried man
1i
:y the following described property in the City of La Quinta, County of Riverside Statc of California;
�1 ok 2 paty 3 O� ivla �J
v Lot 22 Unit �1, Desert Club Manor, as shown by map on file In/��ie �T(c a t tv oun&' Recorder,
Riverside. County, California.
e �AIICIIW00111
Document Date', November 10,_ 1095
srnt'r.'cst? A>ytt o` to ..).SS
cofl '�YOF _ )
p-
t%:I) be ore --
pc.minallyappeared
yn rsclnally known to me (or proved to me oli the basis of satisfactory evidence) to he the perm1nfj lwhcme nflmeW is/a WSubsc:',bi:d It) the within
instrument and uknowleagcd to me thet he/66&A tcy exccutcd the s:unc in hix/weir ituthorizcd eapecily(i#N�and that by his%irerftirt:it signaturc(s)
o", the instru ent the person.(# or the entity upon behalf of which tite personO acted, cXc(:t'W0 the instrument.
vti'1'i ;;\ViSS m hand slid official seal
signalure .!.____ %✓tom_`
This arca for official nolatia seal.
DIANE sE.DN k
Comm. h 1001731)
Nniary "rulr{a (al;!i>mi:r
1°)'1'/' t
Mail Tax Statements to: SAME AS ABOVE or Address. Noted Below
ASSESSOR'S PARCEL NUMBER
• COUN-jY OF RIVERSIDE HEALTH SERVICES AGENCY 6 %- 3//
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
APPLICANT: Submit this form with four copies of a SCALED plot plan (1-20 SCALE) drawn to County specifications as indicated on the attached check list.
non-refundable filing fee is required when the application is submitted. Check must be made payable to the County of Riverside., Approval of this applica-
ta- 1 --Yb 16:WG0U1 1b5:
n shall remain valid for a period not to exceed one year from date of payment.
' 1238 4214.0(
LOG # CHK 02714'.. OC
A ant, Contractor, Contact erson
U mgrytXiw
Address City State Zip
RC1 �C• 9-7-7 1- 4 Cir X25 j
Telephone
19 Seo- 535
Q
Owner "
F0 Q77 Ad' $ Ox ` C� 00 I WTA State Zip
Telephone
Z
°
Job Property Address
/Q e kras4 V
City
(�, CA
F-
,a .ra
U
Lot Size
Agency/W II
Use of Permit, P/P, SUP, PUP, etc.
Legal Description
uWi
.pWater
X I
`,VWp
D S I
Dwelling, Site Prep., etc.
T
Si re f Applicant
Date
w
w
CHEck BOX IF REQUIRED
❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required
❑ Grading Handout Provided
m
❑ WQCB Clearance Required
❑ Staff Specialist Lot Inspection Required
Z
0
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
❑ Date Lot Inspection Completed: Initials
UJ
U)
❑ Special Feasibility Boring Report Required
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Soils Percolation Boring Report by i Ie Ur4Pro)ect # Date
Soils Map Page Soil Type Approved 8y Date
No of Systems
Type of System(s)
No. Dwelling Units
(1) Septic Tank
Soil Rate
Grease/Sand
O Holding Tank O Replacement
4UExisting O Addition
Bedrooms, Fixture Units
3 (��fr��
100Gal.
/
27r �z�Gff
Grease Intcp/Unt Trap
Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
Lead Bed sq. ft. of
Bottom Area
Ft.
ff. rock/ sq. fL.running ff.
Install Une(s) tt. long:-��ft. wide with
Bottom Area
Inlet Tested Depth 0 NA
min. Inche .rockb w drainlines or
U
Proposed B tto Tested Depth
Z
Leach lines/bad special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
O
Total Depth
Allowable
Applicable
I
c,.I�
4- 3
Depth
W
N/A_XOverburden Factor
0 5' �6'
(O
TD
N
Well Review Approved: Date: Well Drilling Permit # f~
SIGNATURE -
S7�
Grading Pian Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
REMARKS:
This application Is A PROVED ENIED for the category checked in SECTION B
FOR OFFICE USE ONLY
above, regarding the g of a subsurface disposal system as Indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
'
21 `f cid
Ing permit is necessary for the Installation of the above -designed system. No construc-
Revenue code Fee S •
tion Is permitted In the required reserved 100% expansion area.
/ O
(1) optic Tank must be 100' minimum from any wells.
Check #
(2) Leach lines must be 100' minimum from any wells, including expansion area.
- "
Date /Q -319� Initial ! � '
1351
(3), Sewer lines must be 50' minimum from any wells.
r
Z
O
(4) epage pits must be 150' minimum from any wells, Including expansion area.
i
ig lure of Health Official
1
Date
DOH -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
1 .
' i• /AGPICULIURAL CO MASSIONEP
• • 'r.• P.OBOX 1009 `} d ; •
•• `, � '• �, Itivtnsu�r c� vzsm loon a
JAMES O. WALLACE " rtlor•1p (om),276-3x700
Aorloulhrrol Cortxnbrlonor FN( (1n) 2.76-3012
bhooloi of Wobhb A Moowie�
EI3-612 Av.entie' 45 Stilte 7
Illdlo.p, CA .97201
: ( 61 9) 1163-11291
CALVIN Co KAMINSKA
/Whlonti Cornniuloner
VAN MLEY
Spahr, Woiahli & Moorur
N (qG?) 2763030
�' FAX (902) 2764728
VNIE 12 3 / 9 -- -- CASE, NO. . e C /l S 12
DEVE1,011"It'S NAM-!
o ,_ y' Z: S
,d
6/y -3�'G-
Dear Developer.
• ACter reviewing'_.yvur.. a..rtalelscttlr•1rr�- pl`f1'rrs`, All y plrinl maLerial I lsted Is not In .
violation of yitarn"tfile lows govertting Lhe Coachella Valley. If su69titutions.
dp occur rind they d"iff.er from plali't material HsLed, this office must be`
notified immediately'.
'I'ltartk you for protecting and prescr,Y.ing the Coachella Valley's, pest -free --
ettvironment .,
Agriculturrtl Commis ner. s Off.lce
cc! Indio and Riverside
E •
S Ah .-
' �t ra 11
°•: ICBQ Evaluation Service, Inc.
u nuR. '
° `�"` A subsidiary
Cem corporation of the International Conference of Building Off leis 5
Report No, 2267
EVALUATION REPORT March. 1989
Covwy'6 �OEV ICRC? Ev,,lv�i:on Senrt. int. '
Filing Category: INSULATION --•
DOW EXTRUDED POLYSTYRENI>r FOAt11 INSULATION "I -:richSTY ROFOAMt
tbrand plastere ready board insueation o, 75*Fo forfinch thick-
STYROFOANI'" BRAND INSULATION AND DONS � � n sat37n*F:z ye n temperature. At a mean temperature of 400F, the values
GRAYBOARD INSULATIONare S.4 and 4.3. specttvely. See Table No. 1 for various insulation types
THE DOW CHEMICAL COMPANY U.S.A. and thermal r . stance (R -'values).
POST OFFICE BOX 515, fication: The maximum flame -spread and smoke -density rat
-
GRANVILLE, OHIO 43023.0815 ings for the foam plastic core at a maximum 4 -inch thickness and 4.0 pcf
1. Subject: Dow Extruded polystyrene Foam Insulation STYRO- density, are less than 25 and 450, respectively.
FOAM" grand Insulation and Do orayboard I,tsulation. E. Special Uses: Dow extruded polystyrene foam plastic may be in-
stalled on the walls of crawl spaces with no coveting applied to foam plastic,
II. Description: A. General: STYROFOAM'" brand insulations and
Dow Grayboard insulation are cltrudcd p,>lvstyrere foam products de-
ntgned for use as thermal. insulation and nonstructural insulating sheathing
The boards are installed in single or multiple lavers, depending on design
requirements. The type of boaro used is determined by its purpose methitd
of attachment and the materials used for framing and finishes.
B. Specific Products: 1. STYROFOAM brand square edge Type IV
insulation has machined ed$es and smooth extruded skin faces suitable for
mechanically or adhesively applied finishes.
2. STYROFOAM brand residinE board Type IV insulation is similar to
STYROFOAM brand square edge and is 1/2 inch to thick ncss.
3. STYROFOAM brand tongue and groove Type IV insulation is similar
to STYROFOAM brand square edge except with tongue -and -groove edges
to provide intetiocking ioints.
4. STYROFOAM brand toreue and groove channeled Type IV insulation
ss similar to STYROFOAM brand tongue and groove insulation except for a
groo••_d surface to receive cementitious finishes.
S, STYROFOAM brand residential sheathing Type IV insulation i,, simi-
lar to STYROFOAM brand square edge insulation except for a plastic filth
facer on both sides to provide improved damage resistance.
6. STYROFOAM brand roofing material Type V1 insulation has ahigher'
minimum compressive strength specifically for roofing applications.
7. 5TYR0F0A;%1 brand plaza deck. Type V11 insulation is similar to
STYROFOAM htand roofing material except for a higher. average mini-
mum cotnpressive strength for certain roofing applications.
8. STYROFOAM brand RV panel Type VI insulation is similar to STY=
ROFOAM brand square edge with more precise thickness tolerances for
laminated panel systems•
9. STYROFOAM b. and high load 40 Type VI insulation is similar to
STYR0170Ahf brund squire edge excep! for a higher minitnum comptes-
sivc strength for conditions where this is needed.
10. STYROFOAM brand high Inad 60 Type Vll in,ulation is similar to
STYROFOAM brand square edge except it has a higher minimum compres-
sive strength.
1 I . STYROFOAM brand high load 115 Type V insulation; is similar to
STYROFOAM brand square edge except for a higher miri:rtum compres-
sive strength.
12. STYROFOAM brand piaster ready board Type Il insulation has
machined edges and cut cell faces suitable for plaster finishes•
l3. Dow GRAYBOARD 11 pe X insulation is similar to STYROFOAM
brand insulatiuns except for lower compressive and flexural strength.--
where
trengthswhere these qualities are not critical•
this In
. Thee mal R esistance: The ebrandrplaster ready boardall insula ions is
provided the following conditions aree met:
a. Entry to the crawl space is only to service utilities
b. There are no interconnected basement areas.
e. Air in the. crawl space is not circulated to other parts of the building,
d. The foam plastic does not exceed a 2 -incl: thickncss and a 2.5 pcf
nominal density.
e. A vapor barrier is installed on the floor of the crawl space,
f. Ventilation complying with Section 2516 tc, of the code is provided.
F. Identification: All insulation products are Identified by face mark-
ings, inciuding:
ark•ings,inciuding:
1. Product name
2. Trademark
3. Dame of manufacturer
4. Naive of inspection agency Underwriters Laboratories Inc. (ICER.
Q.A403) •
Ill. Evidence Submitted: Installation Instructions and reports of tests on
flame spread, bond and fire.
Findings
iv Findings: That STYROFOAM Brand insulations and Dow Gray -
board Insulation comply with Section 1712 of the 1988 Uniform Build.
Ing Code, subject to the following conditions.
1. Insulating sheathingboards are limited to nonstructural uses
with other materialused to brace walls and resist horliontal
forces.
2. The foam plastic insulation board is separated from the interior
of the building with a thermal barrier, such as minimum th-
inch -thick gypsum wallboard complying with Sectiutt 1712 (a) of
the code,
3. STYROFOAM brand insutatin$, sheathing covered with stucco
complying with Chapter 47 of the code may be considered a
weather -resistive barrier without building paper or fell under
section 1707 of the code, provided all joints not tongue and
groove are over a framing member and are filled with approved
caulking. The tongue of a horizontal.tongue•and•eroove joint
must be on the lower edge. The insulating sheathing complies
with the Type Il requirements in ASTM C 578-87a, and may be
used with one coat exterior eamentitious wall coatings under the
conditions set forth In the appropriate ICBO ES or NES evalua-
don reports on the wall coating systems.
This report. is subject to re-examination In one year.
Bvalaadon reports of 10.80 Ella/cation Service, Inc., are issued solely to provide in101»+arron to Class A members oj1C80, utilizing the code upon
►t� '' `"""'"`0 a mp1esenting aesthetics ar any other attributes not specifically addressed nor as
which the report Is based. Evaluation
an endorseme -1 l fecomm9non ��se o}'ljte subject report.�
on independent tests ur other technicaldato submitted by the applicant. The 1CB0 Evaluation Service, Inc., technical staff has
This report is base uP /ar other data, tit dael not possess tau facilities to make an independent vvril'ication. There is no warranty by 1CBo
reviewed the test results cess or tmpl d, as to any "Finding" or Other matter in the report or as to any product covered by the report. This
Evaluation Service, Inc.. D rchantabllit
disclaimer intrudes:, but is not limited to, y
`... , .. pa0e 1 of i