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9610-048 (SFD)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commerAg 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 ate 4 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. (,x) 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 K ct tothe workers' compensation provisions of Section 3700 of the labor , I shall forthwith comply with those provisions.�/,_ Applicant r� + 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 pu poses. fSignature (Owner/Agent) r Date f r ' f l PERMIT # CONTROL # BUILDINGPERMIT �, DATE " 1#)l..y; VALUATION «� ; i.3} l •;at, LOT TRACT JOB SITE ADDRESS 49 01.Al ;1AN Fk,llW) . APN OWNER CONTRACTOR / DESIGNER / ENGINEER -350 C'ALLE AitK1rzBA i, 3'+(ii rii,i.1 :t.ltK(?Eir� i .A ( )DINT; CA 022*%3 LA t ft.1iN FA ('A 0225:3 USE OF PERMIT S I) 4:;WWO (YAYFli OR r� Mt :,.,,7-..,.,. A. l.3" �1t�•I " ��:. �i FV f � 7�.1, i1 � i(.',1 :i, l r tiie 11ii' (1A..RAt.*A'AXW r .'1 h';'.S.(p+ `:r �#a.>Irf'►�Ix� i�+H;IH,:tiiln"I�II:�lt! ci)tv:;`t'Ri*,)'1+)N t+j; IUi-0MI-1194KN) $1.276 SO 11I..AN1144'K t,VU 101 (WWI-410..+tlh 11,0u►.18 1 •;i1r �:'111:%a•.'1�. i.sl 'F ll..�Ey IAA• r�+^. it11. t. �) w11,1L1IA.NIe 'M. 11 is: 11)l 00i-,4 2140) *941,00 ( )3(:"�i�t+'Vk1. i i .`i I01 000 4'04i��i�) SN)3-13 i IAAl3(31i47!, 161 1tw)()..414141 ¢17f. 11"RI-44c, N't, 1'1,10N, (RE11) 101 ( )11! 11 liter +; f_13 �. l{lll:llt�f+i till o0o 1 ()lx) 1fdVRAS (IA "I'll 11 ; *1', 1Nit1 44 t 142(�4�) �d,_(sHI $%I ART IN P1110 10PVAC`W(t?i^S) T01-19XW"%4IXK) r s4 rY P►1 fi 1#':�ii.('()+,�",:1'Ri)t''`1'tl:)?t1 ANT) P-i,i'iNa•1.f1;(,F- D' �. DEC 3 0 1996 114 Y111 AV PERNNiff FF rS D1IF NOW CITY OF LA QUINTA (I RECEIPT 6 � DATE DT DATE FINALED INSPECTOR 3� a 3 a s A(,� a' ,ntnlAtn eO1n ti 'fl w a -ntn Si 'TI ptnroro_n?c3 A m d m '10X a o eo (�ca ro °� Vi ~ < m 'v z - 0 OD l2 Y V / N iv C X t� cD tcii 4� _mac o 9 gg R �i .« E.nr � w rom Or y n r m m m Sm c� 0A ac c7 z r z n r O O D � D Q OG m G A cocn r � m n a O 'U y °Qn g C. rom ,d. mn�i �p cci m ai N Co C_ v d m� �p cB n N o m m= to ,o m o.-nmoxoc o y, X N o m C � ,3r n 3 Q n.n9•4.o n -i O, 3 v n. - Q, t—n v C 3 caaar o m O R h c�ii -n 0 in w 0 ° m3 rQ A CL C m TLn » i .. m� �.� m z = O n r > CA r -o v C O � � a r � z o a 0 Z m 0 i 0 z X n 0 V 1�/ ZP.O. BOX 1504 78-105 CALLS APPLICATION ONLY LA QUINTA, CALIFORNIAIA 92253 Building Lf � Address [ X Mailing �� ��� Address C Wt Citl -W' 5o i' NTS" lZi �22 �� Tel. I Contractor ' _T A 4F -M Nva tom`, CDP44. Address ' City lZip ITel. State Lic. ^ & Classif. G Arch., Engr., — Designer Address Cit Zi State y Y td# p Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby afJ�irrn tlat I am licensed urlderprovisions of Chapter 9 (commencing with Section 7000) of Divisio 3 of the Business ar rofessions Cod , and my license is in f fl rce and effect. S GNATUR ✓1 N ' DATE / OWN QR-BUI LDER�gI`CLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason: (Sec. 7031.5,Business and Profoslons 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 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). IJ 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 suchimprovements 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 or proving that he did not build or improve for the purpose of sale.) II 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 contractor(s) licensed pursuant to the Contractor's License Law.) i ] 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 O 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 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 I 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 it 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 applicant Date Mailing Address City, State, Zip BUILDING DIVISION BUILDING: TYPE CONST. /OCC. GRP. b A.P. Number / / DI 10/ A Legal Description Led 23 Inom P7,�ec, Project Description Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation �Cp F r'O�)CVV/_ /5 O 00 �"� PERMIT AMOUNT Plan Chk. Dep. r �� .00 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 Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date 12-etatIt I 1 �S Validated by: •I IValidation: I n tJ 1 �' CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEW- 1ST FL. SO. FT'. @ $ 2ND FL. SO. FT. @ POR. SO. FT. ��, GAR. SO. FT, CAR P. S0. FT. WALL SO. FT. @ SO. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR :YYSTEM BAR SINK <� ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING �. c NOTE: Not to be used as property tax valuation HEATING (ROUGH) FLOOR DRAIN FORMS MECHANICAL FEES ROUGH WIRING WATER SOFTENER ROCK STORAGE VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) HEATING (FINAL) APPLIANCE DRYER REINF. STEEL GARBAGE DISPOSAL TEMP. POLE FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY WATER HEATER AIR HANDLING UNIT CFM FINAL INSP. KITCHEN SINK BOND BEAM ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET =$ COMPRESSOR HP POLE,TEMIPERM LAVATORY FRAMING HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. @ c BATH TUB VENTILATION SO. FT. © c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID @ 1 V. c SEWAGE DISPOSAL FIREPLACE SO.FT.GAR @ 3/ac HOUSE SEWER SPARK ARRESTOR GAS PIPING GAR. FIREWALL PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING R AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING cu. yd. $ plus x$ =$ LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL Desert Sands Unified School District Notice: 82-879 Highway 111 Document Cannot Be Duplicated Indio, 92201 " - 619-77755 -3500 CERTIFICATE OF COMPLIANCE Date 12/27/96 No.. 15126 Jurisdiction Owner Name Tom & Sharon Kennedy No. 48751 Street San Pedro City La Quinta .zip 92253 Tract # Lot # APN # 617-301-018 La.Quinta . Permit # Log # Study Area 118 Square Footage _3347 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 1.84 X 3;347 or $ 6,158.48 the property listed above and that building perm and/or Certificates of Occupancy for this square footage in this proposed ro•ect ma` `r o 'be issued P P Y q g P P P, -.i y Y.. Fees Paid By cc/Downey Savings/Thomas Kennedy }'Telep;ione- Name on the check ' By Dr. Carol McGrew Administrator in Charge �,• �� ' is •,x:n ; . ' ': {, a:•',.j,. t' ' Fee collected /exempted by Pauline Pearson Payment Received $6158.48 Check No. 3610013592 Signature NOTICE: Effective January 1, 1997, Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to collect them on the District('s)(s') behalf, whichever is earlier. " Collector: 'Attach a copy of county or city plan check application,form ,to district copy for all waivers. Embossed Original- Building Dept./Applicant Copy -'Applicant/Receipt, Copy - Accounting Signature of Deolerant or Agent determining tax —Firm Name x.+R „• t rn J., fi;, r -,F rYF, ti.�✓r ? ! 'S _• h .� X666 C. ce''t � J�•' C-. -.* 'A <tt r"•' i .. GRAN' DEED _ - .. .14 �_ ,arm .. �`, • A VALUABLE CONSIDERATIOIy, receipt of which is hereby acknowledged, `;'$' CHARLES Q.'DE.MARAJ1S, A MARRIED MAN AS HIS SOLE -AND SEPARATE PROPERTY i-;� AND, SUZANNE - KENNEDY" '' AN UNMARRIED WOMAN ... :.; . - :;. AND THOMAS ALLEN KEtNEDY A MARRIED MAN ,• i• hereby GRANT(S) to ' 7 THOMAS ALLEN KENNEDY AND. SHARON KENNEDY, HUSBAND. AND:.WI•FE; AS• JOINT; TENANTS f Y the.•real property: - in 'the City of LA QUINTA ' County of.:°. 'RIVERSIDE • State of California, described as / LOT 23.OF LA QUINTA GOLF "=Y96-98 `INCLUSIVE OF MAPS, ESTATES NO. 1 AS PER MAP ON FILE IN BOOK 3.7•, PAGES , IN THE OFFICE OF THE COUNTY RECORDER OF SAID COUNTY., M_ _ +�x"'F Dated•�:Y STATE OF CdWFORMA 2.COUNTY OF ` R i v.e r s i d e r Am * before me; Yvette Garza—Muela "No.tary Public - t: , Peroonaly appeared THOMAS• ALLEN'KENNEDY/ / / / /T/ / / % F3 . personally known t0 rite (or . Ptd to me onthe basis of satisfactory evidenos) to be the person(s) whose name subscribed to the within instrument and aokrwwled ed to me ecubd the same taumf her / Instrument r/ their siynaturo(s) on "CIA1 SEAL: acted ex I ) u behalf of wh pe )L%_SYVME GARZA-MUELA'US C•r/IUPoRNU1MTNE CIPAL OFFICE INSignature EVim RWftIDE u�b v 24 M Form3les MAIL T TATEMENTS AS DIRECTED ABOVE I � 1 ASSESSOR'S PARCEL NUMBER RhNfiY OF RIVERSIDE HEALTH SERVICES AGENCY 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. A non-refundable filing fee is required when the application is submitted. Check must be made payable to the County of Riverside. Approval;of this appliga-, tion shall remain valid four a period not to exceed one year from date of payment. LOG # l ,ti a ✓ _ �:i ry C ' i� °';' I Agent, Contractor, Contact Person Perpnson AddressCity Q } @A ' State Zip \ ��7� Telephone .1'�•= 4 �� � �j ��•l �•:f" �e� l� `4'�!", �%'l�:, y�✓�iV/�S ��'ir!'3��61�i� f CZip Owner Fes„ Address City State Telephone Z Job Address City Zip yProperty CP U w Lot Size Water Agencjq#ait Use of Permit, P/P,SUP, PUP, etc. .Legal Description (n �' y ( �' I^' � �.` uud. c, o� �t Gu '� �vGi � c> �L` Li;�C�N�iI'dJ .���� �����/F<'��� y°• A �,, Dwelling�MFJ.Site.P-,rep,, etc. -� � Signature of Applica%tM;,,1V ;4 Date t ?h 0A CHECK BOX-IF'REOUIRED ❑ 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 w ❑ Date Lot Inspection Completed: Initials 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 Lic/Pro)ect # Date r Soils Map Page f c l Soil Type Approved By Date G, No of Systems Type of System(s) No. Dwelling Units (1) Septic Tank Soil Rate Gfease/Sand O,Holding Tank O Replacement 0`New Bedrooms, FAxture-Units Grease1ntcp/tint Trap O Addition 0 Existing 2 a o' ��:� Gal. ,a�. h�_ i, ,:Yy�� G�'s� �' Gal. �ttq. Ft. om Area otal Linear Sid wall Allowance �a ft. rock/ sq. ft. running ft. �y' instal�-na(s-)—ft. long tt. wide with Leach Bed sq. ft. of Bottom Area Area Inlet Tested Dept ❑ NA min. indZes rode below drainllnes or Proposed Bottom Taste Qepth U Z Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other: O Total Depth Allowable U Applicable �_ 9 De p th W --- N/A Overburden Factor Oat (b 6' gr l �+ l"3 TD b� �i f Well Review Approved: Date: Well Drilling Permit # SIGNATURE Grading Plan Approved: Date: SIGNATURE Sewer Verification Approved: w_Date: �`nQ ` ` REMARKS. n 1; i,, i� /, .�J," ice✓ .-�j/ !; ;,!% y T/ti c /' /vt . N v re G ii /',v�J��1� �j /i, `l�A �`r"r y. / TMJ ✓`)1/`f ,� , J ;? d This application is APPROVED/DENIED for the -category checked° In "SECTION B FOR OFFICE USE ONLY above, regarding the design of a subsurface disposal system as Indicated on the acompanled plot plan, using the requirements set forth in SECTION C above. A build - Ing permit Is necessary for the Installation of the above -designed system. No construe- Revenue coder Fee s° tion Is permitted in the required reserved 100% expansion area. (1)„Septic Tank must be 100' minimum from any wells.; - ' ��"j� ,�' 0`Check # (2) Leach Tines must be 100' minimum from any wells, Including expansion area. Date G ` Initial t7 (3) Sewer lines must be 50' minimum from any wells. fit � = R �� ,� Z 0'(4j' Seepage pits must be 150' minimum from any wells, Including expansion area. LU Signature of Health Official Date DOH -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDEN ROL—Plans/Records