9905-198 (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
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).
O 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.
�( ) 1 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:
Cartier Policy No.
ST AT 4 T
(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,:.,
j Applicant
Warning: FailurA'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. R
1. Each person upon whose behalf this application is made & each person at 9
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 be 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 building41
'
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)---'��� �'. Date
V .--� i
BUILDING PERMIT PERMIT#
5iAi.5-'4 s1S
DATE VALUATION 591,08,70 LOT t,T n1 TRACT }ALK 14
JOB SITE gg'
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
E,t� i�1.)xP:'f.4 r' I�'1TJ13t�S
`fit+fl,LTAM R11:,` IJ, ROCIE .:
110 soX 3578
_565-400 JACKSON
PhI &I OFSVIRT CA -.92761
"i7=i.#:itl IAL CA. 92274
(760)39`1-11400 CUO `149
USE OF PERMIT
StINGLF FAM]lL' I"1WRI.UNG
8F.19 - KkNfi F DOG d NOT R4t:1.MX:-hL0 CK. WALL OR flOO .. T.QP-DAI
MkC1' CONSTRUC i ION 1,4 75.00 S
1'ORCU(PAX10 ,x+8100 SF
t: rARA(:ii~/l:;AILPt:ItT 463,(Ju S.
5 T. WOOD FaNCE 200.00 1 &
PERMYT FES: SaINJARY -
C"oN5'C.[2ilC rioN 1 101-000-41"00
r1r,ANf;fTf?G,"f�.FF , 1011-0t)(l4N-31 A, $tt4.U,
,Ns-C1.T,WC,V.Imm, 1,01.-000-42.1.000 ' S66, 50
,
ix TR.16A1 FEF' $=30.39
P1,UM1JNG FFB 101-00-419-01k $I33.5t1
S['a2t'a7�fC7mo roN
GRAMM) r. j -1i ,. 101.000.421.000 szoo)
WF URYLe,t`fir, 225-1{}()-443-34A" 32,0 Ki.26
11KFCVJ PLAN'
r. F f3 i�C,1SI :...
Y
k i
r
C09STR_ U TION1 AND FLAN C IECK
$3,509,41
.HSS M.-NVID FUIES
PAM
4250.00
JUN 0 41999 'TI)TA , NOW
U3.58.41
-ITY OF to bUINTt,
r
RECEIPT
DATE i
BY?'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
—
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
!O- IF —
Exhaust Fans
O.K to Wrap
r
F.A.U.
Framing
Compressor
Insulation
—el — S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final / — —
BLOCKWALL APPROVALS
POOLS - SPAS
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
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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)
COMMENTS:
44
:. P.O. BOX 1504 APPLICATION
NOOIL 6 1999
Building _ 78-495 CALLE TAMPICO'�'llAddress eelXQUINTA,
CALIFORNIA 92253
owner
L,4 , ,u��o r i7re T, � � � I V ski b"
Mailing }y � BUILDING: TYPE"CONST. OCC. GRP.
Address r�-0 1�"'<� (' f,
A.P. Number '� �i z; r.. % • �..!=%
City Zip Tel. ' r
V -U J 0 1 12, Legal Description � �'% G ! ! '�'%�.� •� + �.�
Contractor-! r+
.--! A"'., Project Description
Address F �* I
City Zip Tel.
State Lic. I City
& Classif. % Lic. #
Arch., Engr.,
Designer
Address Tel.
City (Zip (State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
70001
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 rile 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 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.)
VI 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 7 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
C] 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 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 fo the Workers' Compensation provisions, bf the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
-F�
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.) y
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.
1 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
Sq.No. /
g7—
No. Dw.
SizeFt.d /7 Stories 0
Units
New Add O Alter O t
Repair ❑ Demolition ❑
i
Estimated Valuation
f
PERMIT
AMOUNT
Plan Chk. Dep.
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 Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
Date 6/4/99
No. 18856
CERTIFICATE OF COMPLIANCE
APN # 773-251-002
Jurisdiction La Quinta
Owner NameLa Quinta Partners Permit #
No. 52-300 Street Avenida Juarez Log #
City La Quinta zip 92253 Study Area
'Tract #. BLK8 Lot # 21 Square Footage 1,475
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 1,475 or $ 2,846.75 the property listed above and t a building
permits and/or Certificates of Occupancy for this square footage in this proposed project^may nowabe issued F -,
Fees Paid By ccNIB/William Russell Roger - Power Brokers ie p ones 399 « 200 r►>'
Name on the check +^�
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,846.75
Check No. 195101
Signature
INOTICE: Pursuant of Asset(ibly 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 fron(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 Dislrict('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
sA-
RC District - Plann * Review Form
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential)' District, in order to determine the applicabitity of compatibility issues or need
to require the filing of Master Design Guidelines by the applicant. It shall be transmitted to
Building & Safety as your correction list. Please attach additional explanations as necessary.
APPLICANT: W. R. Rogers - Desert Resort Development
PROJECT
ADDRESS: 52-300 Avenida Juarez
APN: 773-251-002
LEGAL: LOT, 21 , BLOCK . , UNIT , S.C. @ V.L.Q.
CK'D BY: Leslie Mouriquand
BIN NO: .
CASE NO.
99-64
CHECK DATE: l-- `5Y
Inform- the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
JEL-REQUIRED ITEM
Y
N COMMENT/CORRECTION I
V R
'�V
\+
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file las applicable)
S' =!/ - �l17
MDG filing required (5 + filings since 9/3/98)
Consist&ncy -with-street/surrounding area:.
Colors
Materials
Architecture'
�o
/I
OTHER REQUIREMENTS:
The zoning code, architectural and landscaping manuals, and/or assigned inspector should
be consulted where uncertainties arise. The completed checklist shall be maintained in the
Building .& Safety address file.
RECOMay.25. 1999:7 2:35PM
POWER BROKERS
AND WHEN RfiCORoED MAIL. THIS DEED AND,
UNLESS OTMERWI98 $MOWN BeLOW,
MAIL TAX BTATBMENTG T0: ,
!Wiill= Thomas 110fin
Power Brokers
P.O. Nos 134
La Qainta, CA 92253':
No. 2210 P. 1
SPACE ABOVE THIS UNE FOR RECORDER'S USE
The undersigned grardor(s) declere(s): Grant D"d A.P.N. 773-251-003
Documentary tranefer tau Is 4 —0—
( ) computed on full value of property conveyed, or
( ) computed on full value less value of lions and encumbrances remaining at time of sole.
( ) Unincorporated area: ( ) City of , and
FOR A VALUABLE CONSIDERATION, reeelpt of which Ile hereby aftowledged,
WILIZ!>.M 8. 211=1 TRIJ OF 7M WIW.I= R. SZLIt'>Y 1990 TRUST
hereby GRANT(S) to
WMI M T8a!W SUFFIX. an umoarried man
the roll propeAr In the City of La Quinta , County of Riverside
• 8tete of Cailfomia, described as
Lot 21, Block 8 , Basta Catmsa,ita at VAU La Quints, Unit Va. 1 ,
as per map recorded in Book 16 , paged 46 , Riverside County Reoorder
Dated April lb, '1999
State of Cah7ornle )
CounN4 ALver9ide ) 88,
On before me,
personally appeared
penonafly known to me (or proved to me on the buts of NUehotory
evldame) to be the perser(s) whose names) islare subaoftW to the
wKhfn Instrument and acknovAudgeo to Me that helehalthey executed
the eerrhe In his/herllh* authorized capedypee), and that by
hlahharhheir signature(s) on the Instrument the pareen(a), or the entity
upon behalf of which the persan(e) sated, executed" Instrument.
WITNESS My hand and eMMI sell.
Signature
MAIL TAX STATEMENTS TO,
Signature of Grantor
Ai11 R. 111ey, Tmates
.Form 3196.4 (6-04) THIS FORM FURNIINED BY COMMONWEALTH LAND TITLN COMPANY
Certificate of Occupancy
City of La Quints
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:
Use Classification: SFD
Occupancy Group: R 3
52-300 AVENIDA JUAREZ
Type of Construction: VN
Owner of Building: LA QUINTA PARTNERS
Building Official
Bldg. Permit No.: 9905-198
Land Use Zone: RC
Address: P.O. BOX 3578
City: PALM DESERT, CA 92261
By: STEVE TRAXEL
Date: 1-13-00
POST IN A CONSPICUOUS PLACE
J
Inf0Y'f�1G�tion
®To Build On
Engineering • Consulting • Testing
REPORT OF FIELD COMPACTION TESTS
TESTED FOR: LARRY SHIELDS PROJECT: !752-300 ' AVE JUAREZ 1
LA QUINTA, CA
DATE:
August
03,
1999
OUR
REPORT NO.: 073-90187-2
TEST DATA:
(1) Fine
to
medium sand.
OPT. MOIST. =
10.50
TEST
NO.
TEST
DEPTH
ELEVATION
SOIL ID
NUMBER
MAXIMUM
LAB DRY *
i DENSITY
WATER
CONTENT
WET
DENSITY
DENSITY
PERCENT
COMPACTION
COMMENTS -
Spec . 909. Min
1
8"
FG
— 1
118.0
9.2
121.1
110.9
94.0-I1
- A
2
811
FG
1
118.0
9.6
119.8
109.3
92.6
1 - A
3
B"
FG
1
118.0
10.1
120.3
109.3
92.6
1 - A
4
8"
FG
1
118.0
9.9
118.5
107.8
91.4 �1
- A
TEST LOCATION:
1
2
SE
NE
corner of house
corner of house
pad.
pad.
2. BACKFILL
3. BASE COURSE
3
NW
corner of -house
pad.
C.
D.
4
SW
corner of house
pad.
MOISTURE BELOW SPECIFICATIONS
NOTES: TESTS PERFORMED PER ASTM D2922-96 & ASTM D3017-96
DENSITIES SHOWN: Lbs. cubic foot
'COMMENTS: 1. FILL MATERIAL
A. TEST RESULTS COMPLY WITH SPECIFICATIONS
per
WATER CONTENT: Percent of dry weight
2. BACKFILL
3. BASE COURSE
B.
PERCENT COMPACTION DOES NOT COMPLY
WITH SPECIFICATIONS
PERCENT COMPACTION: Based on maximum dry
density obtained on sample indicated by
4. SUBBASE
5. SOIL CEMENT
C.
D.
RETEST OF PREVIOUS TEST
MOISTURE IN EXCESS OF SPECIFICATIONS
soil ID number.
6. OTHER
E.
MOISTURE BELOW SPECIFICATIONS
. * (1) ASTM D 1557, Procedure A
TEST INSTRUMENT:
REMARKS: PSI did not monitor the material placement
ff
TECHNICIAN: Juan Nunez
THESE TEST RESULTS APPLY ONLY TO THE SPECIFIC LOCATIONS NOTED AND MAY NOT REPRESENT ANY OTHER LOCATIONS OR ELEVATIONS.
REPORTS MAY NOT BE REPRODUCED, EXCEPT IN FULL, WITHOUT WRITTEN PERMISSION BY PROFESSIONAL SERVICE INDUSTRIES, INC.
STANDARD COUNT M: D:
ADJUSTMENT DATA M: D:
Respectfully submitted,
Professional Service Industries, Inc.
PSI A-100-2 (d)F Professional Service Industries, Inc. • 42-240 Green Way, Suite C • Palm Desert, CA 92211 • Phone 760/341-5790 • Fax 760/341-5794,