0008-384 (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 Ezp. Date
4_
1t
Date Signature of Contractor- -�%`•`
7.
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).
(;) .1, 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.O. for t, is reason
Date /M :-. :a i 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..
( ) I have and will maintain workers' compensation insurance, asrequired 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):
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 Califomia, 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 r` i ,, •<u-
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 purposes. '
Signature (Owner/Agent)' r- a' -_r Date
J
'BUILDING PERMIT PERMIT#
DATE +` VALUATION LOT ()1 't TRACT
DC5
JOB SITE
APN
ADDRESS
Qa i w �v�ry �+ y,T�*}r� �+q p
3 SD -510 Sri 9 4r.4i�.I.�+A TIT a Vt�®F1[y.A ..
M-510
: '! O0 -474-f M
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f
3`r9t":�'.k3.,�SCd.E • •
.i��'r� �+Ebl�'i �"�1°1a"i.�tU?:�AZ���
Po Box 1.589'
PA1,::614 n inxr Cwta 92261
60
MINI "DEMM CA 92260
(160)345-3521. C1`; t 4.320 T
;
USE OF PERMIT
X ,19,311 AKWLY DVP_- WG
SPI) , PERMIT OCIPS NOT INC:I:,i.101? BLOCK 'tPtf'.+~ LI S, FOM, Ol+r,Dt:.2VEIV Y,
APPROACH
P0R2:tiPW its
TRACYC C'01q SUMMON DF
FEED SIT -101 -004.439;.316 42,50.00
MtkN CHFA K 17M 101-00()-439-318 $9.f,R'.33
CONSTRUCTION "M 101-00 0,418-000 SM00
MK,CHANJV,A1, F49 $10.00
KLEt;1' IC AL RU ..1411-r5�420.000 $171.01
PLtt1t 8,NO FEE 10,1 000419_000 $216.56
STRONG OTION VEF . 1001D 101-000-241-000, V9.50
$CliIN?1. 0�-00042Y4)00 $�q0,
�l3ipU
f
JE ya0PER i1iACn FEE
SV.L'.)-..ROJ.AL 60NMVITIMIk.1'N .E'ANJ...' MU.NJ,o 6,nC.1.I7ri K
W"�.a.230.� 4 .
+
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
Forms & Footings
_�.
Ducts
Slab Grade
�'
Return Air
Steel
Combustion Air
Roof Deck
-C.
Exhaust Fans
O.K. to Wrap
p m
F.A.U.
Framing
_ 0 - =rN
Compressor
Insulation
- _ _
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Ol
Drywall - Int. Lath
c S
01
Final
POOLS - SPAS
Final
BLOCKWALL
A PROVAL6steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
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
o
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
--�
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) ®-
o�-
' ��cv
7E- �/ P.O. BOX 1504
APPLICATION ONLY
Building 78-495 CALLE TAMPICO
Address 4'd)o;�QUINTA,
CALIFORNIA 92253 �"7D •� l� �/�'j�'
Owner ,� A % I
U-:�o C; h I V G -. 4 -*.—
Mailing
Address (F O
City lZip ITel.
t 1 5 5 if..f1-7L0 3y1_
Contractor
Address
v4i d2,
<, GNU . ' .1 2- 2- -3t7 G o y - 3 S.?
State Lic. ty
8 Classif. L9 �/ i S_ (c. #
Arch., Engr.,
Designer • ��� �%, i
Address Te..>r
f1t.b os. 6 y Z 9AG G- aoZ o
City f ( JZip
q State 1, 1 J Lic.#
LICAF SE�COJITRACTOR'S DECLARATION
I hereb affirm that I am tic ns rider rovisions of Chapter 9 (commencing with Section
7000) of ivision 3 of the Bum sand P ofessions Code, and my license is in full force and
effect. %1�4 A
/ OWNER -BUILDER DECLARATION
Ihereby 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, 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 (8500).
F2 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.)
I1 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
doesnot 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.)
i7 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
F3 Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it 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 mariner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, alter 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
UILDING: TYPE -CONST. OCC. GRP.
.P. Number /
egal Description
roject Description
11 AArPt =D//r1--
Sq. Ft.
Size
New
WNITE = FINANCE YELLOW = A
No.
No. Dw.
Units
Add ❑ Alter ❑ 1 Repair ❑ Demolition ❑
ilk
ifimated 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: Dateermit',
Validated by:
Validation:
j,
PPLICANT PINK = BUILDING DIVISION
f1 S
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 1/3/01 APN # 770-174-006
No. " 21434 Jurisdiction' La Quinta +
Owner NameBen Nance Permit #
No,. 78-510 Street Avenida Neustra Log #
City La Quinta Zip 92253 • Study Area
Tract # DC Lot # 195 Square Footage .3070
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
9
This certifies that school facility fees imposed pursuant to
Government Code 53080 in the amount of
2.05 X 3,070 or $ 6,293.50
the property listed above and thatbuilding�` '
permits and/or Certificates of Occupancy for square footage in this ro osed project may,- bei sued ~�'!
P p Y 9 g P, P P J
Fees Paid B CASH - Ben Nance
y
�Y,
e r,760-345-5521
T.'ehphone
Name on the check,
By Dr. Doris Wilson
4.
Superintendent
�•
Fee. collected /exem ted by Annette Barlow
Payment Received $6,293.50
Check No. N/A
Sig nature
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 data on which the building or installation permit for this project is sssued or on which they are pair) 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
RECORDING REQUESTED BY:
CHICAGO TF LE COMP .NY
WHEN RECORDED MAIL TO:
M S - U I PAGEr-I SIZE I DA I PCOR
CO, SMF MISC.
BEN NANCE
46642 Arapahoe Way
Indian wells, Ca. 92210
_S.I A I R I` L II I - I COPY I LONG I REFUND NCHG EXAM
G RAN T D E E D
The undersigned Grantor(s) declare(s): Documentary transfer tax is $ -67--
.ASSESSOR'S PARCEL NO.: 769-141-006(X) computed on full value of property conveyed, or
TITLE ORDER NO.: ( ) computed on the full value lessliens or
ESCROW NO.: encumbrances remaining at the.time of sale
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged:
EUNICE LLOYD, AN UNMARRIED WOMAN
hereby GRANT(S) to BEN NANCE, AN UNMARRIED MAN
The following real property in the La Quinta, Riverside County, State of California:
described as: Lot 195 of besert Club Tract Unit 5,, as per map recorded
in Book 21, Pages 61 & 62; itn the Office of the Recorder
of said County.
Date: May 30, 2000
EUNICE LLOYD
STATE OF CAL'IFORNIA )"
COUNTY OF t} ( ✓E 9S jVD )
On 4,--1--00 before me, the undersigned,
Personally appeared L Z(NCC.r
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/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 hd a d offi�al seal.
Signature /, // /l J(�/' 1'
OPFICIAL SEAL t
i ANN CROUDY
COMM. #1102128
�•�
Notary Public - California
RIVERSIDE COUNTY t'
Ir My Commission Expires
JUNE 20, 2000
(This area for official notarial seal)
MAIL TAX STATEMENTS TO: 46642 Arapahoe Way, Indian Wells, Ca. 92210
l7Tit's Co , has .
213619-2-16924 i ru, °,r "N For:., ;rr l c:aa� on!
y
IIIIII IIIIII IIIIII II IIIIIII III �IIIIIII III VIII IIII IIII 0sr07r2eof 2s ° 0eR c end ,or i{ to i^;n . icc� :n i::?` .' « an re -'1 -fol
property thst may IV., S:`_ ,,.. ti °
Certificate of Occupancy �a .
City of La Quinta
Building and Safety Department OFTM
.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: 78-510 AVENIDA NEUSTRA
Use -Classification: SFD Bldg. Permit No.: 0008-384
Occupancy Group: Fk 3 Type of Construction: VN Land Use Zone: RL
Owner of Building: BEN MANCE Address: P.O. BOX 2589
Building Official
1�
City: PALM DESERT, , CA 92261
By: STEVE TRAXEL
Date: 09-17-01
POST IN A CONSPICUOUS PLACE