0101-235 (SFD)LICENSED CONTRACTOR DECLARATION
I hreby 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. CNS 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.
(�4' 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:
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 t the w rkers' compensation provisions of Section,3700Aof the Labor
Code, I s all fo with comply wit,)hose provisions.
Date: t� ' Applicant - 3 �a
Warning! Failure to secure Workers Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is*hereby made to the Directdof Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. t
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuan
.any permit issued as a result of this applicaton agrees to, & shall, indemn ,
& hold harmless the City of La Quinta, its officers, agents and employ�e,�s�
2. Any permit issued as a result of this application becomes null and4idtlf
work is not commenced within 180 days from date of issuance of such, .
permit, or cessation of work for 180 days will subject permit tobiFpror"r
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this`City.to enter upon
the above-mentioned property for inspection purpos S. �-
t�
Signature (Owner/Ageht)'t �' �""" Date
C�t� BUILDING PERMIT PERMIT#
TRACT
E VALUATION LOT TRACT
.. n ..;dTsa 1f P.T; .I NO ADR
JOB SITE
APN
DDRESS
25430 AVIUMA, JUJU
774-0714W
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PAMIC' TRUKDl7..eS C01JMRV(-, l0.W
;f A T ;�A�.ChISy.Sy CaN1917r GCV1�r 1;
�51��`.q��.�011
S t7C; r te4 3 �a+: C A. 1+2:54
a OCIUMVIDE CA, 920454
3.935
USE OF PERMIT
0'3t3:1m1, Ty�T,f1C1
3a;fflj w �XA i -136R ,98 JSA- I PLAN) MlU -1 c)OF' 'NOT r.NC1,U131K S1:0cK,
W&M, P(** , OR. 4.JR4MMAY APPROACH,
TRACT CONISTRUICTION' I'Surm 8F
6iMP f;.TIO 5.fi.00 SF
<_'$ARAORfCAlrPDXT (STO. %6'74,90
5 F"r.woO.ri FENCE 390.00 LF•
y, ry� y��rp+�yy^ y gy,�r��p
FSTp g �ryg�+ (114,
B .S. O Cn.l9 i1.r: �LiO.iYA7.6.ti.i.,�4•�.3.R4/d.i
c+u70�i7�Jix.7W
pp��••��� cCqqpp��� y�y�.� �syy��;; (,^�TM�p� •p�,
X-.tiiSCJf.Y ETFF. E X71 �4.%JO�,S: RY
CIONW)"'RUC' ION FUR 101 -000-410-000 $6.1110
PLAN CHECK FV, 101-000•4:39-318 $34:3:45
ff u Z,ANTC 1, : 1� 101.000-421.000 36010
T;1Z1C 7VC.kL FEE 101.000—N20,tJr; 0 $131.151
PUUM—nmo WIF 3 01 1110.7.5
,S 11 1`10 ML VON FEE' • s -S-31-+ 101-.000-241-000 31
ORADI'901ER '101-000,423-000 MA.
r!',U'CiBA MAN 101-000-441-345'ME
09POSIT
Ilk y `
a
a�.
ME, -TOTAL Ct3MM.LTC'.iON ,A$" r,.PLPN CM
.mss=4�4ErQ.�i S
LEDS 111F,19 -FAM IMV
42.50.00
m
RECEIPT DATE
BY
DATE FINALED ,
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
3MMMO
APPROVALS
-Wiv ECHANICAL APPROVALS
Set Backs
_�
Underground Ducts
Forms & Footings
ADucts
XT
Slab Grade
Return Air
Steel
-
Combustion Air
Roof Deck
O.K. to Wrap-(
%
q-(O�
Exhaust Fans
F.A.U.
Framing
�j)
��
S'�
Compressor
Insulation
�_`
�T
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
����p�
ST
Dryvall - Int. Lath
3�01� - OIL
w' -Z
Finan
FOOLS -,SPAS
SLOCKWA
PROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping'
[?[1 Ua 131HO -APPROVALS
Gas Test
Electric Final
Waste Lines
_ _
I
J�
Heater Final
Water Piping�
1 ?� O�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sir Lateral
Pool Cover
Sir Connection
oZ=(_3 �d(
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
2 - 1.2 -O l
_T
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) A, .� I
/
�_ c
151
Building
Address �"T y G• ilvG
4
P.O. BOX 1504
78-495 CALLE TAMPICO
2LA QUINTA, CALIFORNIA 92253
Address / 7 /,:�7- Sr %fit /v101L I
City Zip Tel.
c'zysgl I C? 7- 00� i
Contractor _
Address
City Zip Tel.
State Lic. .. City
- & Classif.
y 2-':;' Lic. #
Arch., Engr.,
Designer
Address
el.
City P Zi -.1 State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with 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,ausiness 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 file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Sectior. 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, 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. It, however, the building
or improvement is sold within one year of completion, the owner -builder will have :he burden
of proving that he did not build or improve for the purpose of sale.)
I 1 1, as owner of the property, am exclusively contracting with licensed contractors to con•
struct the project. (Sec. 7044, Business and Professions Code: The Conifactor's Vicense Law
does not apply to an owner of property who builds or improvesthereon?and who contracts for
such projects with a contractors) licensed pursuant to the Contractor'sYLican se Law.)
171 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
r] 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.)
Icertify 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., It, 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 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 applicant Date
Mailing Address
City, State, Zip
.( - seems
/3 (d - s ��� 4y_
APPLICA 140 ONLY
P162�
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 774L 47, 0-069-5
Legal Descriptiorl/li/ u—/8
Project Description S '
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
3
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical am
Plumbing
S.M.I. JIii
Grading
Driveway Enc.
infrastructure ILOM loop,,"
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
s Front Setback from Center Line
1 Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: t Date Permit
Validated by:
Validation: c
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
1
5
Notice:
Document Cannot Be Duplicated
Date 1/26/01
No. 21575
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NamePacific Trades Contruction
No. 53-430
City La Quinta
Street Avenida Juarez
APN # 774-071-009
Jurisdiction La Quinta
zip 92253
Permit # 0101-235
Log #
Study Area
Tract # BLK183U18 Lot # 16 Square Footage 1501
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
2.05 X 1,501 or $ 3,077.05 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 CC - Capital Bank of North Country.7 David Miller 'T lep,hon 760-967-0069
Name on the check 3
By Dr. Doris Wilson
Superintendent,
Fee collected /exempted by Annette Barlow Payment Received $3,077.05
4—kX)N
Check No. 080100
Signature .
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 peril 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') behatf, 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
Dec -18-204 11:3Sim' --' From=COMMONWEALTH LAW TITLE
REdORDING RRQOESTED BY:'
CHICAGO TITLE COMPANY COMPANY
10584KC 20705817-8
WHEN RECORDED MAIL THIS DEED ANA,
UNLESS OTHERWISE SHOWN BELOW,
MAIL. TAX STATEMENTS TO:
DAVID ROSS MILLER
t
1719 SOUTH TREMONT
S. OCEANSIDE, CA 92054
+7603413215 T-875 P.001/001 F-938
,3u4eF--z.
,5r3 tg-o (+V J CAQ,,e5-' 2 hl— T H
GRANT DEED APR: 774-071-009-5
The undersigned grantor(s) declare(s):
Documentary transfer tax is $27.50
(XXX) Computed on full value of property conveyed, or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
I ) Unincorporated area: ( ) City of and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
JACK CLARK, A MARRIED MAN AS HIS SOLE AND SEPARATE PROPERTY
hereby GRANT(S) to
DAVID ROSS MILLER, A MARRIED MAN AS HIS SOLE AND SEPARATE PROPERTY
the real property in the City of LA QUINTA, County of Riverside, Slate of California,
described as:
Lot 16, Block 183, Unit No. 18„ Tract Santa Carmelita at Vale La Quinta, as per map
recorded in Book 19, Page(s) 31 inclusive of maps, in the office of Che County Recorder
of said County.
Dated December 2, 2000
State of California
County of
On
before me,
S.S. JACK CLARK
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/are subscribed
to the within instrument and acknowledged to
me that he/she/they executed the same in
his/her/cheer authorized capacity(ies), and
that by his/her/their signature(s) on the
instrument the person(s), or the entity upon
behalf of which the person(s) acted, executed
the instrument.
WITNESS my hand and official seal.
Signature
•MAIL TAX STATEMENTS T0:
11
(This area for official notarial seal)
i
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 the Building and Safety Department as your
correction list. Please attach additional explanations as necessary.
APPLICANT Pacific Trades
SITE ADDRESS 53=4v Avenida Juarez
APN 774 - 071 - 00§ BINNO.: CASE NO.: 200-38.6
LEGAL: LOT 16 BLOCK 183 UNIT S.C.@V.L.Q.
CHECKED BY: ' Wally Nesbit 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
Compatibility Review
Case logged and number assigned
Verify legal and APN information
sa-�K cuter- - vw�
I�PLilM7uti ,S-lf--J OA-%Ii0 a* Mlwc
Consistent with MDG on file (as.applicable
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:.?
� A.�a.1f.S
0L O Colors
Materials
Architecture
Other Requirements:
roved by: at Reso
tanning Commission
ity Council
ommunity Dev. Dept. a�
als —
#
U vivzi'e-7 /��vsia%� a-•�-�r��c,�a.,
Cp �5E co L �� s c�wr,r,eM- '173f
Case No. 02 8
.Exhibit—�'
,,,1%With Conditions
Certificate of Occupancy'.
City of La Quinta p�
Building and Safety Department � oF,.E°
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
53-430 AVENIDA JUAREZ
Bldg. Permit No.: 0101-235
Type of Construction: VN Land Use Zone: RC
Owner of Building: PACIFIC TRADES CONSTRUCTION
Building Official
Address: 1719 S. TREMONT
City: S. OCEANSIDE, CA 92054
By: STEVE TRAXEL
Date: 06-14-01
POST IN A CONSPICUOUS PLACE