0008-401 (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
.110 C36
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 providedfor 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;provlsions.• Pte`
Date: Applicant - %�•f �'-.
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 1t4
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 si
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
/ i.0..
c `' r�'•� ' /Date �^ 1.
Signature (Owner/Agent), '� /
BUILDING PERMIT PERMIT#
DATE , VALUATION LOT �yOS-.[a�, ,, . TRACT
JOB SITE �` "r
APN
ADDRESS
5X. A'Ilk':.NTDA.I`#AV=110
774-094-M
OWNER
CONTRACTOR/DESIGNER/EN INEER
DXX SHAW 4 `
DGH 3a7r �d �k.rC3i� i 6E�'C. f:f�Ji�
PO 33OX ,?19's2.
78.9.21 RUXIlsV7'A 1ST
PAIMMEIRMr CA 'x"22(,1
BERM .JDA UfTNU CA 9".251
(760)360.3306 Mot 1526 .
USE OF PERMIT
b'M'X- I'll°.RMd.'P'Oi3.FS NOT INCf,f. DKI),I: L DCK WAU, 0A POOI6ArPtel."!AM i
i)RSVPWAY
`Y'il�.�t°'Y C���"'['i3•LSG'Yi=�7�9 t.���.Qlt 5P
SF
P9Os k1t�p:'i�%y0t•?b?fA"3p's't4�.)�Cspq
i An.00
1.its,�:Bt:OPYC✓J`f.xWB'b�PIT (3I) %e"9..P1 o
31< T. VMOD 1Oi:"�M $.J+'
n�Y.7Y.!� �.f �. �%A'
93X 6 '{0
dy�y� p p er.1Y.p��
dc`.Cr.S40@'.9d: d:.4�r•IIe32�:fD8:eATli9#.U.aw4AXR.:6
PER 101 -000 -418 -WO $612.30
PLAN L°HWK FEE I O7 •(t�3t?� ����5 �f $:5�3d.�3
MECHANICAL FF9 WIN)
'KLZY, R1..C:.s 4 YM, ' Y t�1=OUi3 X20-ffOt� �.f tii.a8
PLUMBY1110 FEE 101-000-419.000 X310.73
STVIONO MOi IM nZ — r.F 11) 101-OOD-241-000
GRADING PER
FRY, �3A,grt�:lnityt
2£1lI.'i•Y��v�t}�tJ�I?f211i�k.TMP.d's�''
I1 gyp y; t p
TPI -000-441-345
%").'%LSIC SY, MAN �� !,'wdi°'4°1,i4�"f�"'F1.°1345
'KE , DFA) Ei P
31" ral'A3:. Co PLAN' Z~nK:.E
V,4 8.87
a LOS PREPAID KsF3
4250,00
OCT 0.9 2000'• rfn rxpmarx77x-sIn now
0,11 �I;
it LAt
RECEIPT
DATE a
r9Y' r `
DATE FINALED
INSPECTOR
4.. INSPECTION RECORD
OPERATION
DATE
INSPECTOR
_ BUILDING
APPROVALS
Set Backs
Forms & FootingsV-11
Slab Grade
y3 _.0
_ s
Steel
Bond Beam
Roof Deck
/ 2_ Y o 0
5-7
O.K. to Wrap
Framing
Insulation
z=iy, aQ
r7
Fireplace P.L.
Final
Fireplace T.O.
PLUMBING APPROVALS
Party Wall Insulation
Waste Lines
Water Piping
Party Wall Firewall
Plumbing Top Out ( G
Equipment Enclosure
Exterior Lath
1Z _ 2-?_ ov
S7
Drvwall - Int. Lath
/_ . 07 _,n
c ir
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
Final
I ' �L0 ( I
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
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out ( G
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection �p �� X00 S?
Encapsulation
Gas PlDina
I
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:
;01 • ��
X11 . I
Building
Address
Address PJ 0 i
ress
T4ht
"
P.O. BOX 1504
7b-495 CALLE TAMPICO
tA" LA QUINTA, CALIFORNIA 92253
Zip Tel.
SIG/ t .'•
71 _(riI1 9uki/aWitft /S6
City Zip Tel.
ISefc-m;,dh 0U../(- 1 36 U-Cii( 6
State Lic. City
& Classif. ( r �' Lic. #
Arch., Engr.,
Designer f (' 40 e J S 0
Address V / Tel.
City. Zip State
L
. (� Lf L L Lic. #
LICENSED CONTRACTOR'S DECLARATION .
I hereby affirm, that I am licensed under provisions of Chanter 9 (commencing with Section
7000) of Division 3 of the Business I d'Professions Code, an®d m iFlice s�eys�''n full force and
effect //�r�iiY/4� /��/1��.�:.C/
SIGNATURE :7- F' / 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 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).
I-1 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. If, however, the building
or improvement is sold within one year'of'completion, the owner -builder will have the burden
of provingthat. he did not build or improve for the purpose of sale.) _
I'1 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 impioves thereon, and who contracts for
such pi0jects with a contractor(s) licensed pursuant to the Contractor's License Law.)
t7 I 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
FJ 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 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 slate 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 sof this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
WHITE = FINANCE
ff ,
.. _— 1 1 --
6
APPLICATION ONLY
i
BUILDING: TYPE'CONST. OCC. GRP.
,A.P. Number 1 1) U Cil 9 fo
,Legal Description{ S� '�i 2 P't t2 a
Project Description L0. 1: b -it Q
G CIl–faa;
SFt. No.
Size
Stories Stories Unitss
New ❑ Add ❑ Alter ❑ Repair,❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep.,
Plan Chk. Bal.
Const.
Mech.
Electrical ;
Plumbing'
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback frorr Center Line
Rear Setback from Rear Prop. Line
et Setba^ c from Center Line
i e S tib ck from Property Line
FINAL DATE— INSPECTOR
Issued by: Permit
gW
ValidatedStSy':/�
J � Y
Validation:
I
YELLOW = APPLICANT
s
N
PINK = BUILDING DIVISION
r/ 01oo C $ -
Doo S� 4o i
Building r�r
Address 1 1 A"d
Owner /
Mailing
Address V ZX sr .I
y Zi Tel.
Cit P
s do 06 sv��
�IGf��iiV �o R
P.O. BOX 150.4 APPLICATION ONLY
78-495 CALLE TAMPICO /
LA QUINTA, CALIFORNIA 92253 Z)/
Contractor I
:= v r"1 J) _/I /I i t) f�
State Lic. Cityc. q
& Classif. t/, f-� r
Arch., Engr.,
Designer (' J
Address �, Tel.
City Zlp State
#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm- that I am licensed under provisions of Chatter 9 (commencing with Section
7000) of Division 3 of the B Inese�fd'Professions C , and m ,11cenaej*.m full force and
effect.y6 •..If
,�%/_
j
SIGNATURE " / DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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, after. 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).
L 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.)
1*1 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'! I am exempt under Sec. B. a P.C. for this reason
Date Owner
i WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
1 Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
j Policy No. Company .
I r7 Copy is filed with the city. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed lt 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
i Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
i subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
Ii
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 stale laws relating to building.
construction, and hereby authorize representatives sof this city to enter the above•
mentioned property for inspection purposes.
Signature of aQplicant Date
Mailing Address
City, State, Zip
WHITE = FINANCE
2b
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number L i Ll
Legal Description " 3 C% I/ A 4. • �}-'
Project Description
1
f
Sq. Ft. No. NoDw.S/v�
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
' n I /
PERMIT AMOUNT v
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 frim Center Line
Rear Setback frcm Rear Prop. Line
Sid% t Setback from Center Line
$Ioe'S t , ck from Property Line
FINAL DATE f NSPECTOR
arp+
Issued by: Dated" Permit
�1 y �, •,
Validatediby: '• j)
�i c
Validation:
YELLOW = APPLICANT
PINK= BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: S La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE ,
Date 10/4/00 APN # 774-094-016
No. 21049 Jurisdiction 'La Quinta - -
Owner NameDale Shaw Permit # 0008-401
No. 53-345 Street Avenida Navarro Log #
i -
City La Quinta Zip 92253 Study Area
Tract # Lot# Square Footage 1533
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 of this time due to the following reason:
EXEMPTION NOT `APPLICABLE ' a
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
2.05 X 1,533 or $ 3,142.65 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now b'e iissued .
Fees Paid By CC / Palm Desert National Bk. / David. Heusinkvel Telephone 760-360-8706..
Name on the check?.�* `
" . By Dr. Doris Wilson i
Superintendent
Fee collected, /exempted by Annette Barlow Payment Received $3,142.65
s.
i Check No. 081348
Signature 1.61
c
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9D -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 Distdct('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 Copyr- Applicant/Receipt 'Copy - Accounting
06/28/2000 08:00A Fee:6.00
Page 1 of 1 DQc T Tax Paid
Recorded in Of,Ficial Records
RECORDING REQUESTED BY County of Riverside
FIDELITY NATIONAL TITLE INSURANCE COMPANY Gary L. orso
Assessor, County Clerk 8 Recorder,
AND WHEN RECORDED MAIL TO:
- DALE M. SHAW
J _ I IIIIII IIIIII IIIIII I I
I IIIIII III I III III IIII IIII
-�
�� � � t ER
U PAGE SIZE DA PC NOCOR SMF MISC.
�z2s
S1{, 7 ` ./ C
� 2, L COPY LONG REFUND NCHG
A.P.N.: 774-094-0161,—TRA #: ASYA4, Order No.: Escrow No.: 14 -1613 -MB
020015 GRANTMEED I n
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY 22.09
[ X ] computed on full value of property conveyed, or
f computed on full value less value of liens or encumbrances remaining at time of sale,
unincorporated area; [x] aY of _ I -a G2111'v� , and
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged,
'RUBY L. DALE, a Widow
hereby GRANT(S) to DALE M. SHAW, an Unmarried Woman `
the following described property in the Cj4y of La QVI nAa//VACANT LAND, County of Riverside State of
California;
LOT 5, IN BLOCK 214, UNIT NO. 20 OF SANTA CARMELITA AT VALE LA QUINTA AS SHOWN BY MAP IN
BOOK 19, PAGE 38 OF MAPS, RECORDS OF RIVERSIDE COUNTY, CALIFORNIA.
't
Y L. DOE
Document Date: June 20, 2000
STATE OF CALIFORNIA (( )SS `
COUNTY OF�rV'e�.S, Ci�e--, ) % /
On o .O a before me, Eta r (J �' h't <_' ✓
personally appeared
personally known to me (or proved to me 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/their 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
This area for official notarial seal.
OFFICIAL SEAL
_ •� BARBARA CONNEL
COMM 01202290
d Notary Pubic - California
r C7 RIVERSIDE COUNTY
My Commission Expires
DECEMBER 16, 2002
c
Mail Tax Statements to: SAME AS ABOVE or Address Noted Below
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 regir'xe 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 DGH Development
SITE ADDRESS 53-345 Avenida Navarro
APN• 774 - o94 ti BIN NO.: CASE NO.': 2000=305
LEGAL: 'LOT 5. BLOCK 214 UNIT 20 S.C.@V.L.Q.
CHECKED BY:. Fred Baker. 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
Y
COMMENT/CGRRECTION
Compatibility Review
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)
s
PROVED By CO UNITY
XHIBIT
Consistency with street/surrounding area:
Colors
' Materials
Architecture -
�SE N0.
r
Other Requirements: _
Certificate ofOccupancy
AF
i�. .
:City .of :La Quints
v
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: 53-345 AVENIDA NAVARRO
Use Classification: SFD Bldg. Permit No.: - 0008=401
Occupancy Group: R 3 Type, of Construction VN Land Use Zone.: RC .
Owner of Building: DALE SHAW Address: P.O. BOX 2982
City:. PALM DESERT, CA 92261
By: . STEVE TRAXEL
df"'l Date: 02-26-01.
Building Official