9901-094 (SFD)LICENSED CONTRACTOR DECLARATION
1'fiereby 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 # ii �Lic. Class Exp. Date
QW u :s Fr ci
Daj{ r
te Z / Signature of Contractor�r r'.t`'
L
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).
�(,,,)'11 am exem t under Section B&P.0 for this reason
V Date 7 ? 'l ti{% "Signature of Owner „'ei lA. e .Its t, Le
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 riot -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: l 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. qq
Signature (Owner/Agent)-2-1/%` 11
I1— ! „_ lt��r � k Date � `�✓�
• BUILDING PERMIT PERMIT
9%)1 04
DATE VALUATION LOT LOT(j TRACTJOB
ADDRESS '�,8-� 20 A.'b ENIDA .1lle'tt.REZ
APN 74-071-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r ��.� ,"� pp
At i� r`i a.R+L'�.. t l.�ei ii VA'. . -I.Al.•3.�:sii:�. i��s
Olt. -AN N,a.i ).;:At +t,.,?>AT7`T? S t P+.^.%(-r•i) n "['t`\'C�
l..<k4r a.. A
!UAVON IDA l�..ARRlfs.N4,'%.
%^2120AV N A. l.A&R.t'ti�f..��
1,.AQLJIN-t'A (:.A' 922Sj
L-AQl:!INIA CA 9.2153
f;�E:s!3)ifi4-apt t E"�P;f,3� � 11i
USE OF PERMIT a
SWIT.► PERMIT D' *h' S NOT OR POOL. PLAN
0fi-X ,1lQf 11tQN 011, E 1~I�S l; Ul iJ%;.f:t "da tJi 191Ji 'd'1F'!.t t 3t3.l1t�f< T7 i 3A
::.AME tai;AN 'VYPJ;. ,
r
1��:►Rr;siv.i?;�'ii+'3 ` 1i.'„.E)? Nf�
k�Ait�lc�+l fa t�t2ltt i'.°1` 4530) SF
- - XCIS JR.X&THI-1 f Mw ' ` d, 70�_ fi,.Y YI1i b'6 .si4^ 7 i3.QJ.Y
ii4�Y<8t <r'i!
CONT 31Rz,1MCYN FEF 1411•-000-40-000 $6C+1�•tfE3
'0,Ali',C,4 ,,'KVIM
FEE D!:cs34.14?.4..4 , •.sL..:
'JUE:,TRICAL FM 101-000-420-000 $125.21
PUT"111 t RE,, 101-000419-000
S11RON+^31vr:~3'1'TON F03, - :tiMED, 101-000-241.0)
GRAD1:NCG 101 OOf�»4 3-#? wti.E�+3
I NNF'3rWT1tUC TURF FEE 22:5-fM-d,13 342
PRIFvCrSF ;PLAN 101-000-441-145
Ct; ID-Tfd MAT, COMST`_T IXTON .}!'ND PLAN CHECK
$Vrli) R7
LESS tPTIT-n:x.11:1 FE.1.,s
-$2_V.00
` O'fAt VIt, RMIT i'CES 1)UU'NOW
52.959.9.2
/46
k CLIP ��
DATE
BY V
1 DATE FINALED
INSPECTOR
\ O v {
T Al.
.INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings.
Ducts
Slab Grade
— —
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Q
F.A.U.
Framing
— Q
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL
P ROVALS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL
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)
APPROVAL
/
!�
COMMENTS:
_
P.O. BOX 1504
Building t 78-495 CALLE TAMPICO
Address 1 t� aYt2� LA QUINTA, CALIFORNIA 92253
Owner
Mailing C►
Address I .i Q t C a m i4 K 7
Cityt Zip Tel.
L-A k►n� 11 ISS 9-)L 3�!!
Contractor
Address
City
State Lic. City
& Classif.Cj6
Arch., Engr.,
Designer
Address
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing wits Section
7000) 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 issuence also
requires the applicant for such permit to file a signed statement that he is licensed p�rsuanf 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 (8500).
l] 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, Bufaness and
Professions Code: The Contractor's License Law does not apply to an owner of proFerty who
builds or improves thereon and who does such work himself or through his own enployees,
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.)
1'1 I, as owner of the property, am exclusively contracting with licensed contractor, 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 cortracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
1'71 1 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
r7 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-.1 valuation
Of 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 shoule 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
1 expiration if work thereunder is suspended for 180 days.
t 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
APPLICATION ONLY
.DING: TYPE'CCONST. OCC. GRP.
Number '77Y 07 � 6)197 � ?
I Description 't7'} i tI-, o 1 '
Project Description
Sq. Ft. No.
Size Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
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: Dat" 'I r 7"A Permit
Validated by: y
JAN I ti 1999
Validation:
V r 1 ,i • J r .r.
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
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 2/22/99 APN #
No. 18378 Jurisdiction La Quinta
owner NameJack Clark General Contractor
No. 53420 Street Avenida Juarez
City La Quinta zip 92253
Tract #
Lot #
Type of Development Single Family Residence
Comments
774-071-009
Permit #
Log #
Study Area
Square Footage 1,505
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
1.93 X 1,505 or $ 2,904.65 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 ccNalley Ind. Bank/Jack Clark Telephone 564-3511
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto Payment Received $2,904.65
Check No. 183137
Signature4A._
NOTICE: 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
RgUQ1�1AG REQUESTED BY: �.
CcL,rORDED.
I � �t'_.
AND WHEN R MAIL TO:
Jack Clark
54350 Avenida Herrera
La Quinta, CA. 92253
ie4 0,-;;�6-0/J'
5-3-4Zo Ave ,Jv4z&Z
COPYof Document Recorded/
on !_iS-- as No
Has not been compared with original.
GARY L. ORSO
County Recorder
RIVERSIDE COUNTY, CALIFORNIA
THIS SPACE FOR RECORDER'S USE ONLY
ASSESSOR'S PARCEL NO.: 774071009 The undersigned Grantor(s) declare(s) that the DOCUMENT TRANSFER
- TAXIS:
TITLE ORDER NO.: 8204326 $ 16.50 County $ city
ESCROW NO.: 18479-004 XX computed on the full value of the interest of property conveyed, or
computed on the full value less the value of liens or encumbrances
remaining thereon at the time of sale
GRANT DEED
� — OR transfer is EXEMPT from tax for the following reason:
< FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
,5 Henry C. Griswold, trustee
hereby GRANT(S) to
Jack Clark , a married man as his sole and separate property
all that real property. situated in the City of La Quinta
County of ' Riverside , State of California, described as:
LOT 16 IN BLOCK 183 OF SANTA CARMELITA AT VALE LA QUINTA, UNIT NO. 18 AS SHOWN BY MAP
ON FILE IN BOOK 19 PAGES 31 OF MAPS, RECORDS OF RIVERSIDE COUNTY, CALIFORNIA
Dated December 02, 1998
STATE OF CALIF RNIA, }
COUNTY OF �i/G2!'`54rkk } ss.
O„ --� laq , before me
Notary Public, personally appeared
personally known to me (or proved to me on the basis of
satisfactory evidence) to be the person(s) whose name(s)
is/arcrsubscribed to the within instrument and acknowledged
to me that he/sho# ley executed the same in lits/her7eir
authorized capacityoes'j, and that by his/har#heirsignature(s)
on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
WITNESS my hand ial seal. _
Signature
MAIL TAX STATEMENTS T
SAME AS ABOVE -
ADDRESS
Henry �Griswold, tru tee
(This area for otficlal notary seaQ
CITY, STATE & ZIP
CINDY BURCIN
to
COMM. X1180893 n
"1
NOTARY PUf3LIC-C.IUFCRNIA
q
SIDE COUNTY M
RIVEMy Comm. �E):rns April 22, 2002
(This area for otficlal notary seaQ
CITY, STATE & ZIP
RC District - Planning 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 applicability 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: JACK CLARK
PROJECT
ADDRESS: JUAREZ
.LEGAL: LOT -1, .BLOCK IR -3 , UNIT S.C. @ V.L.Q.
C K' D BY: FRED BAKER
BIN NO: 5B CASE NO. 99-38 CHECK DATE:
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.
REQUIRED ITEM Y N COMMENT/CORRECTION
....................................................:.�..................:::.:.:.�.:.:::::::::::::.�:::::::::::::::...::::::::::::::::.�.::::::::.�::................................a.
�j:?}:ji::}{;1:;•:?•:r$:•iiv:Yv.::::.v::::.v.:w;•:.v:: N!::::nv.v: •: h:: •!.
......:::n:v:::::::::.�:::w:::::::{::::::;:•!'�i:ri^:^::G;•;x::.:.v:::::::.y::tr:4!:;:;::}G:.i:•}::'•!:i+i: �!:^:i^!!v+•�!:4!i!:>•i:•!!!:
v.:i•....
::.y i � ' is .: :? i'!i'� �•. ��. ??•:: n;::•? .: ............••:w:::::::::::::::.v:::i:::w::::•!:.v:::•.:v:!:::::::::!:::.v::::::::v!: }::v: 4ii}...:::: •::::::::::::::.,;:v!:: v!: •..
C�I�I:I`?ATII�I€1,fT�v.:..Eit:f.Y..:.::.:.::...v::::::::.v:::..................................................................................:............................:...........v: }:!!:?.!:.!:.: �!!:?^}: � :;:<>.::>�:«:;::>::>::!::::::.:
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file (as applicable)
MDG filing required (5+ filings since 9/3/98)
-- Gonsistency-with--street/surrounding-area:
Colors
UNITY DEVELOPMENT DEPT
Materials
Architecture' I X IIT
OTHER REQUIREMENTS: SE O.
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.
Y O
O U
3 m
m
0 0
>
a� a�
N L
O
L O
r �
c=p C
y c0
Y
f0 �
O
U) 3
0
o
rn
Cv
a� a
W L v
J O C
m N
y y
— U
L �
0 3
rn �
c o,
♦r a U
v/ p ol
J
y �
C
cr. o o_ 1
Q co
�- a
V>-je
Q 0 `O
H o
Z Z
O _ C
a)
C.i OM
O U
m VC.
D E
p O
Q U
O
r
D y a
0 _ C
cr.°
Q W _ .N
J m >
O
LL c
O Zc�v
o m
V LUU L
CL
y
_�
>
0
'3 a
�m a
c�
as (D
3
E
N
r
y
L
r
� p
O
U
O
C
c0
y
L
U
W O
C
Q
y
Q'
Q
O
—
Q O
y
m
41
O'
c
0