9805-030 (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
>; .�G666 i f3 ,+ 3/31/99
,q to 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). r
( ) 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.-
( ) 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:
Cartier Policy No.
;: IMIF'I 10114 ON ID.L.
(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
D/ e`, I s all forthwith comply with those provisions:,
te: C: T Applicant 1 f'
i�
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.
ignature (Owner/Agent).-.1,-, -1 P ! t:. r 1. Dates ( -�'
BUILDINGPERMIT PERMITi CONTROL#
DATE VALUATION 93.212 6. 4 0 LOT I � TRACT 117472 6
JOB SITE
ADDRESS 51-245 rSV6',N10A VE, LASCO
APN 773-€364-021. ,
OWNER
CONTRACTOR DESIGNER ENGINEER
e�
SAA4`. Ci itiYqA,,rr'�C`IlVJ(�
p „L
3n�i�E\AVri1�i*Fk 1A.M
Al 0R
4-350 AVENIDA HERRE RA
4-3-A0 AVENIDA E{1:RREILA.
[.A (?IJWI'A CA 42253
ISA QUiNTA. CA 92753
r;7fi4ltSC�4-35 t 3 C�13I;,# III S
USE OF PERMIT
51+"�
8I? - kLWMII 0088 NOT INCLUDE MtXX Wr;., tt iCJ, 7510LAv
1
,
•"�
r":�..'j'e;.'( N"SMUC""t10N I,`rC1,.�o s►� MA
15 1998
F'OXC;H4,11` ,110 17.00 511,
0- ARAi: &1/C.A1010RT 448.0v s _
6 f'. woc) PriNct � (. `iTY Y OF
Lia 0���� � ��
.t:0l It.
Y,
�9s v1JV1 . FER,,'S"b(C%-1ARV
Ct)11 11S tF z;cICTION FIEEI 101-O(IU-4 19 --OW a 1-1.r_V7
YTIANt` IF(;X'i»'ET, $132.19
r R a+ ^i -r, 3 l 1 h
�.�iii.:�.se«lai,.'RI. b�:.r. r.OI-�t�t1••�Ix.i-i10t� SS...SJ
1:1,lsCITRIC AL FBI, Ill1-i3Uil�fl2Vahl[� otfii..i�i
PL U%4 H 114 0 1; EF, ilil-t )G-�tIy-lli3fi $148. 1
11?01N'C; NIO``11'!�1'''(S`►N MTs• . RF311) 104-f0�00-?rJ..+[1,41100 19.itttt
R.!t�,hl[1iN .'4?A:cr., 1011.-00,0423-000 •12111.09
INFRASTRUCTURE FL 225-000443-312 322 5.30
P(Z.tWIISE PL AN I0I-000-441-345 825.00
,f•`1C? i?tiPt?fit't� IS}t-t)tIQ��139-MIC-��(1.00�
St CONSTRUCTRON AND PYA114 CHT,111"
LESS PRE -PAID FEES
_n50.00
T(YFAi,r PERN>XIX F I? CIS'i DUR NOW
44
S2,948.44
RECEIPT
DATE
BY ;1
DATE FINALED
INSPECTOR
l�f
�
ea,
INSPECTION RECORD
OPERATION
DATE
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 L4
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath oe
Drywall - Int. Lath Aer
Final
Final —iEtA2
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
12
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 G,Pool
Cover
Sewer Connection 8
Encapsulation
Gas Piping
Gas Test AnL
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-
l9tility Notice (Perm) - �,
COMMENTS:
Desert Sands Unified School District
Notice: 82-879 Highway 111
Document Cannot Be Duplicated Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 5/13/98 APN # 773-064-021 .
No. 17015 Jurisdiction La Quinta
Owner NameJack Clark Permit #
No. 5.1-245 Street Avenida Velasco Log#
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 1,505
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 1,505 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 60V 06 6 issued
Fees Paid B Cashier Check/La Jolla Bank/Jack Clark °
Y-Te]epnon:;, 564'`35`14 f
Name on the check
By Dr. Doris Wilson
Superintendent :1j, j'+; rt .L x
Fee collected /exempted by Juanita Green Payment Received
Check No. 301619.
Signature
NOTICE' Pursuant of Assem 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 tqb 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
•..f:-'i;3"K..�.Y,i7tl�;:�,..,:i,c.-X^-S �^' ' r.�s..:.,.n,,,,:r. �4, r• '� -r y::- 1+ �.Y +4ri" a %t"t,,; rtr-'--• _ .
Z.s.ri,,r„4�'�,„�'y�y;�,,�'�'�Pt•,..,!"`I/`,� Y �.1'�a. ii'�”�w/�"�^.•`.,-.•t,.Y1'�...tt}:.-h� n.:.,(-� -i�,r.,;�-r�
� d \1 & 14 eD4o
Adildin7)
drress �� U�J ��� t 1`1g��1"i
Owner �, �, L �-a✓r
J��tz 4 1
1604 -n
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
manrny
Address �a� ?�G� /��tE . �'•��ffyetlCG.
City Zip Tel.
1��� stn qa��� ��1S►I
Contractor
�:Y✓l e
Address.
Zip
State Lic. ll City
8 Classjf- 11�.�Cwl Lic. # 1115
Arch., Engr.,
Designer
Address Tel.
City I Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I am licensed under provisions ol�Chapter 9 (commencing with Section
the Busihe�sSand Prote_ssions Code, and my license is in full force and
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 all, 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, 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.)
1'71 I am exempt under Sec. B. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I he, 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. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i! the permit is for one hundred dollars (Ef00) 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 o! Exemption you should become
subject to the Workers' Compensation provisions o! 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.
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 sof this city to enter the above -
properly for property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE•CONST. A e"'i CC. RP.
O7
A.P. Number �� ��
Legal Description t �J -an VAC14AL ✓
Project Description
J 2
Sq. Ft.
Size
No. No. Dw.
Stories Units
Minimum`Setback
New ❑ Add ❑
Alter ❑ Repair ❑
Demolition ❑
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
Date PPAM
Validated by:
f'
Validation:APR
0 3 1998
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
(J • v
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 PPAM
Validated by:
f'
Validation:APR
0 3 1998
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVICOII 1 A OF LLA OLD I I ` TA
RECORDING REQUESTED BY:-
OLD
Y:OLD REPUBLIC TITLE.COMPACOMPANY
98.7135KC 105584-13
WHUNLERE�� 0�RR6SYYIH gqMAIL A44NW
JACK CLARK, JR.
54-350 AVENIDA HERRERA
LA QUINTA, CALIFORNIA 92253
SPACE -ABOVE THIS LINE FOR RECORDER'S USE
GRANT DEED
S!- 245 NE VEk-asco
The undersigned grantor(s) declare(s):
Documentary transfer tax is $18.15
(XXX) Computed.on full value of property conveyed, or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of and
FOR A VALUABLE CONSIDERATION, receipt of t.hich is hereby acknowledged.,
FRANCES GRACE CORK.and JOSEPH CARTER FORD, a married woman and a married man
hereby GRANT(S) to
JACK CLARK, JR., A MARRIED MAN AS HIS SOLE AND SEPARATE PROPERTY
the real property in the City of LA QUINTA, County of Riverside, State of California,
described as:
LOT 11 BLOCK 70, OF SANTA CARMELITA AT VALE LA QUINTA, UNIT q_, AS SHOWN
BY MAP ON FILE IN BOOK 18, PAGE 69 OF MAPS, RECORDS OF RIVERSIDE COUNTY,
CALIFORNIA
Dated January 23, 1998
State of
County of s 7S.S.
on
r
before me, }.� i,q �, 4 V1
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/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.
RANCES GRACE .CORK
-JOSEPWCAIZTER FORDO
WITNESS my hand and ..ficial seal.
Signature /o (This area for official notarial seal)
MAIL TAX STATEMENTS TO: 'Y
SAME AS ABOVE
-AUB IST
CONTRACTOR -,AL�- ����� ADDRESS S4 -'S50 E�rY g
OWNER _ JOB ADDRESS
In
Thea form shall be postea on_tha jnta i h thin Building spa 'on C rd at all times in s cpnspicuous place.
It is the responsibility of the General Contractor or the Owner/Builder to monitor the sub -contractors that
are on this list are the same persons performing the work. Any changes to this list must be approved the
City of La Quinta Department of Building & Safety qLj" to work being performed by a changed sub-
contractor. Failure to comply will result in a stoppage of work and/or the voidance of building permit.
CITY
SUB -CONTRACTOR'S'
TYPE OF
STATE
CONTRACTOR'S.
womt 's
COMP. NAME/
BUSINESS
LICENSE
TRADE
NAME
LICENSE.
LICENSE:,_..
NU MM:.ON FILE
NUMBER/
NUMBER
EXP. DATE
(p
10005 �sqy
�� l:ua�
GRADE/ �V✓
A, F longi/! G/pd;,�
A/C -12
1423013 -q7
�q 1
3
EXCAVATE
1 9>3
►
PIPELINES
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Owc - 342463
2532
CONCRETE/ �✓
FOUNDATIONS
GONG✓G}j, C•0.
a
sI91
ASPHALT
A
L-/
FRAMING
(�-4 eS s T
B
7 D
STEEL/
C-61
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MASONRY
C-29
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PLUMBING
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LATHING
GrA; A `lour
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ELECTRICAL �1�/
�Nol��S ��G�Y�G
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;.�%S 97
(General)
C-38
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SHEET METAL
C-43
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uertirica te of uccupa
City of La Quin'ta
ncy
Buildingan'd Safety.. Department
This Certificate issued pursuant to the requirements of Section 109 of the .Uniform Building Code,
certifying that, it 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: 51-245 AVENIDA VELASCO
Use Classification: SFD Bldg. Permit No.: 9805-030
Occupancy Group: R 3 Type of Construction: VN Land Use Zone: RG
Owner of Building: JACK. CLARK GENERAL Address: 54-350 AVENIDA HERRERA
CONTRACTOR
City: LA QUINTA, CA. 92253
Building Official
By: STEVE TRAXEL
Date: 1-27-99
POST IN A CONSPICUOUS PLACE