9908-152 (SFD)LICENSED CONTRACTOR DECLARATION
I her,�bV affirm under penalty of perjury that I am licensed under provisions of
Ch;,,�ter (I (ccmmencing with Section 7000) of Division 3 of the Business and
Protessionals Code, and my License is in full force and effect.
Licerf,e�f 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&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.
(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 BUILDING PERMIT PERMIT#
VALUATION LOT TRACT
DATE /� 1/51(1
JOB SITE..',"•w;
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
, h(ir �1..Id'1Y C,PIA
P 6 BOX
IA C1000A (.'A 9225-A
t-A (OWFA
USE OF PERMIT
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RECEIPT
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DATE FINALED
INSPECTOR
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BOX 1504
Building 78-495 CALLE TAMPICO APPLICATION ONLY
Address �(f- �,., S I �Yv LA QUINTA, CALIFORNIA 92253
-Ec/ 1Y1 hi 1so ✓)
Mailing J
Address
City ) Zips Tel.
53
Contractor
W1 C, �frc� e�Sv V
Addre s
Cit Z� Tel.
Statei� G 9�, / / City
&Classit. L- Lic. q
Arch., Engr., ,�
Designer `klleAge/ Hurst
Address Tel.
7.3 1,;)5 3y/-�7 qG
Ciy/ , State4l, r 11-ael Z 1 260 1 Lic. #0
LICENSED CONTRACTOR'S DECLARATION
I,hereby affirm that I am, icensed under provisions of Chapter 9 (commencing, with Sectlo
7000 f Division 3 f the"Bus17; a I P� row f sssions Code, and my license is.inrfull�)�f,V,,d)
effect -�i(1/ // !?.Jr"�:j �' /
SIGNATURE r DATE
OWNER -BUILDER DECLARATION
I hereby 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, after. 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).
I7 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.)
I1 I, as owner of the property, am exclusively contracting with licensed contractors to con-
s
trucI 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.)
11 I am exempt under Sec. B. 8 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
n Copy is filed with the city. O 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 thip 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
BUILDING: TYPE'CfONST. y OCC. GRP.
/
A.P. Number U ! 6 - / 1 0 '4,
Legal Description _ L n -L 6-3 . L a C-,- F_ I
/ f
Project Description �f6 141 h 15 PI -1
ZONE:
BY:
Minimum Setback
Distances:
Sq. Ft. No.
Size Stories
t No. Dw.
Units
New Add ❑ Alter ❑
Repair ❑ Demolition ❑
Side Street Setback from Centier iRe P --,Side Setback from Property Ljhe
r
FINAL DATE
INSPECJ'96r, 4
99
Issued by:
Date Permit
Estimated Valuation
� 1 �� 7 „;� ;"� 7 ^ r1, ,....,
PERMIT
AMOUNT
Plan Chk. Dep.
w "J'0
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Centier iRe P --,Side Setback from Property Ljhe
FINAL DATE
INSPECJ'96r, 4
99
Issued by:
Date Permit
Validated by:
� 1 �� 7 „;� ;"� 7 ^ r1, ,....,
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Pale's Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515 t
CERTIFICATE OF COMPLIANCE
Date- 11/1/99 APN # 646-130-022
No. 19526 Jurisdiction La Ouinta
Owner NameEd Nicholson
No. 48-751
City La Quinta
Tract #
Street San Isidro
Lot #
Permit #
Log #
Zip 92253 Study Area
Square Footage 2865
Type of Development Single Family Residence No. of Units l "
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 2,865 or $ 5,529.45 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 ccNIB/Richard T. Dodson Construction Telepho>nc
Name on the check
By Dr. Doris Wilson
Superintendent�
Fee collected /exempted by Juanita Green Payment Received $5,529.45
Check No. 202504
Signature
NOTICE: Pursuant of Ass#mbly 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 f ,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.
Rmhngcerl Original_ Rnildi_no, r)p.n,t,/Applir.nnt f'.npy - Annfirrant/RPeP1pt ('npy - Accmntinbo
•
JUN -09-1999 15:12 N R FINANCIAL 6039290599 P.02i02
C( -Ey ;
f
1111=1 }ING ROQUEMD Jay
ANn Vl4t8M RLCORrnED MA((,TO:
E.G. Nicholson
P.O. Bos 1024
La Quinta, CA 9W3
I Spate Above This Line for Raonks $ Vu Qoty
X. =13044' TRA.A: 0,ZM Order No.r 2134718 Escrow No.: 14.1117-Rw
GRANT DEED
TME UNDERS MMM GRANTOR(c) DBCLARS(s) THAT DOCUMMAkYTRANSFZRTAX ts: COUNTY S121 .00
computed an 11111 value 01
proyyerty conveyed, or
mp
couted on full value leas vslue of liens or enmmbrances rcmaining at tim of sale,
unincorporated area; ( X ] City Of La to , and
tr`F.OR A VALUABLE CONSIDERATION, Receipt oFwhich is hereby acknowicdred,
Y G(trdner and Wilum L. Gardner, Trustccs , or their Successors-in4ritertst of the G irdner Fam;1y Trust
ihleti June z5, 199
h"hri* G1tANT(S) Lo R.G. Michchon, a Marricd Man Sole and Separate )'mperty
the following described property in the City of La Quints, County -of Riverside State of CaMmia
Lot 53 of Lg Quitua Golf Estates Vai't 1, as per map recordcd in Book 37, Pagqs) 96; 97 :3c 98, of Maps, in the Office
of the County Aicardei of said County.
Leroy E. Gardner sad Wilma L. Gardner,
Trustees or their
sunesaors-In-intereat of the Cntrdm.r
Fyalnily ted I e 25�.
By.
L. Gardtur, Trustee
Document Darr::—May17 999
S. ATT: OF CA1.1F0 (A
COUN•rY DF. -
permOrwilY eypared
persdmrt r � • •7/.� ,
Y town (y me (or proved on as bunt of amd$Metory evidence) m Oe Me person($) whose n3ma(9)�e/ore aulricribd eo the wiWin �trumenr
OM1d icWrevPledged to me th t hehherd: Y eaeeured she $amo in h;&6e�/the(r authorized
cru po,oeKq o► du entity upon heh,ll'af wldeh dee wpaclrKms) $nd Lhar by bi&N 's heir aipriltult(e) vn du fnrQhmeyn
penen($J acted. Qx4cuted the iaieumau.
WITNU9 ,11W nfiWol ud
S r ? SYLVIA OAV16 6110
S�rl619f Comm, 11191544
�► u(Jtr:M P11RIC-CAMFONA
�, ldi Adgebf Cdonly •
TOTAL P.02
�'�), tiro.. • - ..
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY �� _ _
DEPARTMENT OF ENVIRONMENTAL HEALTH 333 0
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.
A"Wri-refundable filing fee is required when the application is submitted. Check must be made payable to the. Count'',ofLRive�rsidegApp Dov allof this applica5l
tion shall remain valid for a period not to exceed one year from date of payment,
t • 5201 nrryta{.
5135 $214.(
_
Agen JContractor, Contact Person
13Aotr(J [-')o,-)�G,�,
Address ` City State ! "` Zip
� ��fry �r1h1�` �:.� ��/�i>�a �'� �.2�5.3
Tel'ephone''
1,6056JI.7,�7,�
Owner .
Address City State Zip
Telephone
ZO
Job Property Address
if .
City
Zip
WLot
W
Size
1atpr Agenc " eIP
I A V c 1440 s
Use of Permit, P/P,. SUP, PUP etc.
IDWE, t,,4 &J/As;.' G`t=!G�
Legal Description /, �^
� 9 5 3 Lh 0v47w 6jo- .4' �4 4. 1/46 T'
ellin MH•Site-Prep:, etc('2 S'61 �j,
,�d�N'f_�r
403 J /
Signature of Applicar(t f jPL a/�ti,:�
Date
CHECK BOX IF REQUIRED
If any box is checked, 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
days after date noted below may require repayment of fees.
❑ Staff Specialist Lot Inspection Required
m
0 Holding Tank Agreements Completed
Z
Thomas Bros. Page Grid
0
L] Certification of Existing S.D. System Required -
U
❑ WQCB Clearance Required
❑ Date Lot Inspection Completed: Initials
LU
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑Maintenance Booklet Provided r
❑ Soils Percolation Report Required
❑ Special Feasibility Boring Report Required
❑ Rereview Required Initials Date
❑ Final Inspection by Department of Environmental Health is required.
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Lic/Project # Date
/ d
Soils Map Page / Soil Type �-•• ,4 ~ -
yp Approved By � Date
. � z
No of Systems
Type of System(s)
❑Holding Tank ❑ Replacement
No. Dwelling Units t r3 /rwl
Bedrooms, Fixture.Units-
(1) Septic Tank
Soil Rate
Grease/Sand
Gres Intcp/Lint Trap
New ❑Addition s
Existing
3 6P4M l d A4�.j
/1000 Gal.
I.4 fkA4a4/c�
a
Gal.,
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft. of
Bottom Area
Ft.
�ft. roc sq. ft. running ft.
Inlet Tested Depth
Install Ones) ft. long ft. wide with
Bottom Area
\\\
\ ❑ NA
min- inches roc below drainlines or
Proposed Bottom Tested Depth
0
Z
O
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
'*•�,�,\
�.
Applicable
`,
Total Depth
Allowable
Depth
N
N/A Overburde Wactor
TDA r
'Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved:sl Date:
Sewer Verification Approved: Date:
Plan Check Only Approved: Date:
am pp
A 1.�Gr IG.C' f !�! •• wv
REMARKS:/fj
..
l
/,I ..Y�a ✓ w � 4 9C br /�7 �`f �.a,.ev{iti.j=-rrs.=a' -a's- �P„ 44e'�oy+•
,� ,..�.,.(� �tts�d�iY�
�/.i/�7�/�B
C.•��G �d-l�r_;
This application is PPROVED ENIE&;foth9cyateg_ehectce_dAinAA IZSECyTION B
., ! v FOR OFFICE USE ONLY
above, regarding the design of a subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
ing is necessary for the installation the
r
�.
permit of above -designed system. No con.
atnlctlon Is In the
Revenue code Fee $ C;?/ •V
permitted renulred reserved 100°Y expansion area.
(1) Septic Tank must be�1,01Y'minimum from any welis.y /403
?0
Check # a3 •
r4f f f"'f U'Ef76?
(2) Leach lines must be 100' minimum from any wells, including expans�/a ea .
�y t 9 Q *�- -
Date 16-1919
6 " / 9' / / Initial / Al
0
(3 Sewer lines must be 50' minimum from any wells.
/7. 0, /
Z
O
•,
(4) Seepage pits must be 150' minimum from any wells, including expansion area.
W
Signature of Health Official /
Date
ucnvniv,cc �nov alao� u,�u,uuuun. 1-1IL—U11160 rIM, TCLLUvv—nppllUdI1t1 r-IINN—DIU9. Uepl.; l7UL1JtIVRUL—Plans/Records
J
I '
h
w
• PW
PUBLIC WORKS CLEARANCE LETTER
FOR ,
CUSTOM HOME LOTS
Dear Builder: �.
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 -improvemeints '.
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 i'n'
accordance with the existing soils report and tract 'grading 'plan, and h66-
checked
ave checked and approved by the Public Works Department. ,� t.• ",.
• Tract 28034 (South Valley Estates)
y .. • _ �.1 �..k Y.l r.i
FOR INTERNAL USE BY PUBLIC WORKS DEPARTMENT --,
LOT:,
U LIC WORKS AUTHOIZATION DATE
F: IPWDEPTIDOCSIFORMSIPW CLEARANCE LETTER ss
COMMENTS: ,�S 1%I2�%I�! ~'
T C. L -I&` - j pD
Ln
STRUCTURAL AND CIVIL ENGINEERING
DENISE R. POELTLER, INC.
73.661 Highway 111 • Suite G • Palm Desert, California 92260
14 March 2000
Mr. Tom Hartung, Building Director
CITY OF LA QUINTA
78-495 Calle Tampico
La Quinta, CA 92253
Re: STRUCTURAL OBSERVATION
Nicholson Residence
48751 San Isidro
Dear Tom:
I have observed the structural elements and lateral load path for the
structure referenced above and found them in conformance with _
the structural documents prepared,by my firm.
Respectfully submitted,
Denise R. Poeltler
R.C.E. 33446
DRP
W.O. #99-166
cc: Richard Dodson, DODSON CONSTRUCTION.
(760) 779-0405 0 FAX (760) 779-1317
CIVIX.
STRUCTURAL AND CIVIL ENGINEERING
DENISE R. POELTLER,; I_N.C:
73.661 Highway 11:1 • Suite G Palm Desert, California 92260
24 September 1999 ±
Mr. Tom Hartung, Building Director
CITY OF LA QUINTA
78-495 Calle Tampico
La Quinta, CA 92253 r
Re: Truss Acceptance Letter
Nicholson Residence
48-751 San' Isidro, La Quinta
Dear Tom:
I have reviewed the dead and live loads used for -the -design of gang -nail roof
trusses• provided by SPATES FABRICATORS.(dated'08-26-99) and found them in
substantial: conformance with my design loads.. <
Respectfully submitted, QPOFESsroti
ApF��9
Fyc
W No. 33446,
Denise R. Poeltler s Exp.8.30-02
R.C.E. 33446 *sr cwlv a•
9rF OF Op1.`FOP
DRP/Im
W.O. #99-166
cc: Richard Dodson, DODSON CONSTRUCTION
` (760)'779-0405 • FAX (760) 779-1317