9904-215 (SFD)04
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
w,hapter 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 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&RC. 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.
(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 PERM
DATE 114!?";�1`�"?VALUATION @ ter'>'%11 LOT TRACT
JOB SITE
ADDRESS 4& 730 SAN DI.M.\S �
APN 046••14o
OWNER
CONTRACTOR / DESIGNER / ENGINEER
%1S)NI JhTd3P1'f Off, Co
t, s'`+t 1: = t !)t.I i I ¢;til: w 1l+:'),WS IN(.'
703 2 t.1,"2. RD
PO Box 18(W
GRAND JUNCTION C0 H1505
PALM DESERT C,A
700)141
USE OF PERMIT
til'!a • }1sW1ll2�UM.C�
(IUSU014 C ON S'M(''I'I£» 11-2-W Sr,
PC,IRCI+14Kf to 343.(* 41;
0AltAOlX`CAR11CaRT 6570.0 3F
FSTINIATED lCOS Off' CC1RSTR C€10N
264. 37,90
1%kMJTbTX SUMMARY
C"4: N-3'tRAX.'V1C)N FEE 101-000-41.l4,ft' $1,21' API
P1 ANCtW'k H-,Rt t (114)(10-414- Al 9 $41*141
101 0610-4.39 IN 1$
NIE:."_'HANIC'AL FEE 101 4*6 4211-ft) Sis5.5+r
PIJ IM11TWIT FFV, t iT I-•(t(lil.4
'l'Iti: iivCi MC TION i471, - RE,;) 101..t4CC)4.A$1-W
ORiWINO FEE 101-()00+42.340)
CNF1tA"S"i'f K111T)RE FE,I.1 22. 4)(X)443• 342 $5,949 Ate
ART IN Pi. RLtC PLACI S - RESR.; `ICYI Aper."25S40) $411 34
tiT 411 i"t"�T' 11, C :(1Rad i T{4 K't f(?1�f AND PI,AN ('141"C K
t,l:SS PRE T AID FFFS
$7S0 N)
TOTAJ, PERM11 F IET'St DUF N0W
!btt,245.86
'
rRIE,belftlj a
DATE
BY
DATE FINALED
INSPECTOR
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P.O. BOX 1504 APPLICATION ONLY
Building C c 78-495 CALLE TAMPICO
Address !S �J�%11 / LA QUINTA, CALIFORNIA 92253
Ownermon ►Un g / elo " BUILDING: TYPE'CONST. OCC. GRP.
Mailing 616
Address SsB� � A.P. Number J �/ / �,Q1
City,. dip Tel. Legal Description c�^ `kJQ ,f QT (��9`G6,�
Contr �tor �/�d7 Project Description .J / .f
hv1,.1:;k,uga.t
At:17� Sox
Cit lZip Tel.
5�2
State Lic.�c City
& Classif. �55?n 7 Lic. # Sq. Ft. No. No. Dw.
Arch., Engr., Size �� Stories Units
Designer cJ3r�� New (11" Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I herebyy affl m that I am lip n�ad under rovisions of Chapter 9 (commencing with Section
7000 of,Divis on 3 of the 13 as and fessions Code, and my license is in )u11 force.and
effect. /A ,2-4 . 1 %�/ JI IV �r1:1 � '1 _ // �C�r1
OWNER -BUILDER DECLARATION
Ihereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Susiness and Professions Code: Any city or county which requires a
permit to construct, atter, 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).
I,' 1, 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.)
('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 contractors) 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 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
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 permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work. for which this permit is issued, I shall not
employ any parson 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 theWorkers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby 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 adplicant Date
Mailing Address
City, State, Zip
tstfmateo valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal. t I
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
t
i
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line +4
Side Street Setback from Center Line It
Side Setback from Property Line
i�I.Ic\�•�_rra
INSPECTOR
Issued by: Date ermitt
Validated by: 11)
MMpp
Validation: °"r'IR
I I .'if I y of
LA
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION Q" I Y 7-,A
4
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253 .
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 4/12/99
No. 18567
Owner NameMonument Oil Company
No. 48-750 Street San Dimas
City La Quinta
APN # 646-140-025
Jurisdiction La Quinta
Permit #
Log #
Zip 92253 Study Area
Tract .# Lot # Square Footage 3,172
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 to the following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 3,172 or $ 6,121.96 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' '4
ell<�
r�
Fees Paid By CC/Mesa National Bank/Nancy Christensen Telephone �' w
Name on the check
(ir1�1 4'
By Dr. Doris Wilson .,.,,-, t
Superintendent'
Fee collected /exempted by Juanita Green
Signature
Payment Received $6,121.96
Check No. 88314
NOTICE: Pursuant of Assiftly 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
�:�' i 1F/•
..OM1-'
.L9'
.IT.i i- Irl T r r r. T �
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uLU ht { 6U1.II� I (1 �
:
044177.
RECORDING REQUESTED AYt
: ;7*
OLD REPUBLIC TITLE COMPACOMPANY
i
RECEIVED F'i0R'"ft
+ c
98.7120DT 105570-13
AT 8,OOA .
D
KHEN RECORDED
)
TexUNLESS
PERN
Yti9ti4.,,`
MAIL THIS DIED AND,
OTHERWISs SHOWN BZLOW,
FEB'61998MAIL
TAX STATEMENTS TO:C.R.
BRGWN
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703 23-1/2 R d
Grand Junction CO 81505
Fan 8r4`
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SPACE ABOVE
THIS LINE FOR RECORDXR13.1
:
GRANT DEED
APNt 646-140-025.6 + a;
f
The uiicicr:,igned yi,antor(:i) dcClaie(s)
Documentary transfer tax is $96.25
(XXX) Computed on full value of
p property conveyed, or
`0
Computed on full value less liens and encumbrances
remaining at time of sale.;➢
Unincorporated area: (XX ) City of La Ouinta
and
• ;.
FOR A VALUABLE CONSIDERATION,. receipt of which is hereby
acknowledged,
,. .:
ROBERT C. MONROE, Trustee and MARY ALICE MONROE, Trustee,
of The Monroe Family Trust
dated February 14, 1995
„-
hereby GRANT(S) to
C.R. BROWN, a married man and C. PAUL BROWN, a married man,
each as to an undivided,.!*
one-half interest, As Tenants in Common
the real property in the City of LA QUINTA, County of RIVERSIDE, State of California,
• (�
described as:
LOT 30 OF LA QUINTA GOLF ESTATES NO. 1 AS SHOWN BY MAP ON
FILE IN BOOK 37,
'
PAGES 96 TO 98 INCLUSIVE OF MAPS, RECORDS OF RIVERSIDE COUNTY,
CALIFORNIA.
,s
=u'
Dated Januazy. T1, 1998
• •s;b��..
State of Ca41ornia
Coul1 of S.S. ROB
C. OE, Trustee
'
On-LLtiL11Z tq YT
be ode m,Izi
L�• sem. ��
A. ..
ILL personally appeared MAR 1ii'IC6
61
MONROE, Trustee
r
...
persoria ly known to me (or proved to me on
�'.
the basis of satisfactory evidence) to be
the person(s) whose names) is/are subscribed
' •°t`
to the within instrument and acknowledged to
h'
me that he/she/they executed the same in
his/her/their authorized capacityliesl, and
�•'
that by his/her/their signnture(s) on the ►
■ ",`
.
instrument the person(s), or the ent. i [y 11pC1T1
�9�m
behalf of which theci<:ted, rxecut�d
�"'�`ti.'.f
Y(-
!'cc instrument
``
A. ^f��y..' f.epht t,.r.L„��T4! r'•4^t�t�Yh�rF'iT* fq•..,MW='{tr'�'R' r f^�'��Y'�
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL`HEALTH
PERMIT APPLICATION-TFOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
APPLICANT. Submit this form with four copiespf„a. SCALED plot plan (1-20 SCALE), drawn to County specifications as indicated on the attached check list.
A
non-refundable filing fe required when they application is submitted. Check must be made payable to the County of Riverside. Approval of this applica-
tion shall remain valid for a not to exceed from date s l 9� '14"57C002
period one year of payment.
490
C/T�/ �A
rLlvlS'� df (Yul/✓rA 5135 $214.
Age tC� ntr�ctor, Contact Per on Fo,
Ass ^ City State.. zip
Telephone
MC
�cPF�f,,
Owner
Address City State Zip
Telephone
ZJob
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Property .. ,� A dre s ' w "` Ci
g_ iso S t s� ........ C,a u,
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Lot Size/
116,0- 70
ater Agency eR
BICE/lA.� iY
Use of Peqnit, P/P, SUP, PUP? etc. Legal Description �,//T
DL+,�'lli/{�6 Gr/%A /T. 6A4,oG[/ --T N
3� 14 QuiA/Rf 41OCA 11,90FJ_W/
(2147"/ST%IICT••
welling, lte�arep*etL1(3 /%– L.0
Signatu e o A plica R. W p6 0 Q g /0-99
Date
/Q
CHECKBO)(IQUIRED s'
`
Q'SIrE GA�I &hlcS/6,✓r1,00V;114-0 01 SF.(,JweDls?omI QPM
If any box is'ch ed, this application shall be .considered rejected until
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
the information is provided and the fee paid. Resubmittals later than 90
::1 ' �-
days after date noted belovi may require repayment of fees.
❑ Staff Specialist Lot Inspection Required
ca
❑ Holding Tank Agreements Completed
Z
Thomas Bros. Page Grid —
O
❑ Certification of Existing S.D. System'Required;.
.
❑ Date Lotlnspection Completed:
U
�✓"""`"""
❑ WOCB Clearance Required
(Attach for DOH -SAN-( 07, Santa Afia Region Only),:ei
Initials
N
❑ Soils Percolation Report Required21'Maintenance
Booklet Provided s
❑ Special Feasibility Boring Report Required
p�
❑ Rereview I D'
L]i Final,lnspection�'by Department of Environmental Health is required.
Required Initials /� Date. O `
Please call24'nours PRIOR to inspection.
C/42 / Soils Percolation Boring Rep rt by / Lic/Project # i Date
d
Soils Map Page / I Soil Type P Approved By r. Date
No of Systems
`
Tx pe of System(s)
U 6lding Tank ❑ Replacement
ew ❑Addition
No. Dwelling Units f MqX.
Bedrooms, Fixtere- rSits
3 19QRM 3447H A(luc
(1) Septic Tank
,,
Soil Rate
t
Gr ase/Sand
Greas tcp/Lint Trap
❑ Existing !_t.<.;�k`
/aQ0Gal
d—�•S" i
�O�r
f
/
Gal.
Sq. Ft.
ottom Area
Total Linear
Sidew 11 Allowance
ft. ro sq. ft. running ft: +
Install Line ft. long ft. wide with
Leach Bed sq. ft. of
Bo"
s
r
Inle't,Tested Depth � ''� ❑ NA '�
- v
min. � inches ro_ below drainlines or
�Area
U
J
Proposed Bottom Tested Dept
�.
Z
Leach lines/bed special design for slope:
(3) Pit Diameter"
No. Pits
Pit Below Inlet (BI)
Seepage Pit'
Maximum
Other:
Applicable
1.
r
Total Depth
Allowable
Depth
N
N/A Overburden Factob
TD
4L3
Well Review Approved: + Date: Well Drilling Permit #
SIGNATURE ., . .
Grading Plan Approved: ' �. . Date: "r•
sl f
Sewer Verification Approved: ~' Date: "
Plan Check ON Approved: C( �, RTT Date:
REMARKS -y d+
%LL)� v'
MoGfi►�
/
This application P PPROVED/ ,EN1ED-for-tf�lcategorynhedred;'�;lin;S'ECTION'9
above, regarding t e., eslgn,of a subsurface disposal system as indicated on the
FOR OFFICE USE NLY
57 3J7, 73 S�>`E2tmF� :1t� 37. d G „
acompanied, plot plan, using the requirements set forth in SECTION C above. uild-
ing is
_,••,+,,,,—
/3� ��
permit necessary for the installatio o the. above-desi ned s stem. No con.
3� gyp%/�
Revenue code q g a/ �, Q Q
8 r8 u red reserved 100a/ PYIfanAirin AIOO
g
(1 Septic Tank must be�' minimum from any F/14�►1. T/L�EI
- -
�/ 7–s1�0ir4'
9S�D,Q(
wells°%/Ot+N
(2) Leach lines must be 100' minimum from a�ii wells, including expansion area.
Check #
Dates -3/—,!24 ltlal
ZZ
Q
rrll(3 .� ..J' ...�
Sewer lines must be 50' minimum from any wells.
,.
"1 i
0 4
Z
+
( Seepage pits must be 150' minimum from any wells, including expansion area.
-le -T.
~O
(j
N lO M i v. �/LO e. ''Q�tf.El 9� 1q 72Fi A44 /,I
ld
Z.,
(
Signature of Health Official
Date
- d
n
q90,�_ Zit
Den -SAN -122 (Rev 9198) Distribution: WHi I t—VIIlce File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
Community A.eeocZatZon
P. 0. Box 162
La Quinta Ca 92253
Telephone: 760/564-2177 FAX: 760/564^4882
April 12, 1999
Building and Safety
CITY OF LA QUINTA
P. 0. Box 1504
La Quinta CA 92253
RE: New Construction
Lot #30
C. R. Brown/Monument Oil -Co.
Gentlemen:
The Architectural Committee of La Quinta Golf Estates has reviewed the plans
submitted by Christensen Homes Inc. for the above referenced construction and
find the plans meet all specifications setforth in the governing documents of
our Association.
If you have any questions, please contact the office.
Sincerely,
Anne Tuttle
Association Manager
r
Dear Builder:
T4'yl 4 4 Q"
PUBLIC WORKS CLEARANCE LETTER
FOR
CUSTOM HOME LOTS
Prior to issuance of a building permit, you will'be required to obtain clearance from the
Public Works Department for one, or more, of the following:
1.- Verification that rough grading is complete, and the pad elevation certifications
prepared by a licensed surveyor, or engineer, are on file in the Public Works
Department.
2. , Verification that infrastructure improvements and other required tract improvements
are complete, or sufficiently advanced to warrant building permit issuance.
3. Prepare an engineered grading plan that provides for on -lot storm water retention,
and have it checked and approved by the Public Works Department.
• Tract 26524 (Estancias)
• Tract 26769 (Mountain View Estates)
4. Prepare an engineered grading plan that provides for building pad grading in
accordance with the existing soils report and tract grading plan, and have it
checked and approved by the Public Works Department.
• Tract 28034 (South Valley Estates)
' u8.7�o ��►� 7���5
FOR INTERNAL USE BY PUBLIC WORKS DEPARTMENT
TRACT:Qll(util_
LOT:
Ael OA
PUBLIC WORKS A ON DATE
F:%PWDEPT\DOCSXFORMS%PW CLEARANCE LETfER.ss
COMMENTS: