9907-101 (SFD)r;LICENSED CONTRACTOR DECLARATION
1)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
EDat" a �' 3 f t Signature of Contractors
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.
(k) 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).
`()<f 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
sleet to the workers' compensation provisions of Section 3700 of the Labor
�C • de, I sh II forthwith comply with those provisions.
te: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct..] agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
(.Signature (Owner/Agent) "fif i �t-•�L�� Date ti
PERMIT #
BUILDING PERMIT
DATE VALUATION �j� �� ?,ten j �� LOT TRACT
✓�`,iY4"��i
4� s','_ X1720 ids" '�°4L,� JOB SITE
o
APN 73�f-��-
ADDRESS' ,}fel
OWNER
CONTRACTOR/DESIGNER/ENGINEER
y
e_ 6�bti }f9
r.ynr� A.,��yyr
iAf"ice n,J 4 R%•lihFlo.v%r
11i gg
,id �-i.~0 il.%1:,Yti XT-) fJL, A Al Zil.
ii .'16 AVE' ei,.C�`, :, iti..6i11,•JL'YQ,
t.li t,�4%4tL'I'SL %'A ��s d�,i
1-A (j) :J,.,, M i :ii •� �,{> Y
USE OF PERMIT
q
ti�Y"flil •9'. 4'f�t11l.�eq ��f%bi;t,,ls!I'ii4.!
t -)R
C'troF� itiut'.Gi.Eb`d':�a A`�+'uh�� {d� t1l�IFo+1Yi'-09.6; ::v:ei,a�bdt,$; f_•tl' .iU��'sfS k•�'�nV'? �`piy
1 d, �: ii.. Q '�°i �Y(t��f) ����.P�i✓'s G'l fu�i !o ��C{.°v'h) e,'.R°
4'+s!s�`bLi�af.tAt, d trig -1!
kiAi_ 6t,',1 -'AAAI, f16' >-)1 0fit ;vw
ire o r) s �,Iftwmo r+'
E A "Y¢ •�q (of Ati"(' �:l�i{ �y,'tt!iY'.V+
f:�l iX17184i !�V(-NIr11'7ie
911
iibSl����u'b`�y•a 5�°r.-�o.�ftaid;�azl,�i��
1�'6e N O.At.; 1t?X_()00
B�4II CIf, F0 -P 1{)I-f2fff -A49-199
s`a7� `�fn ri l.. •Gifa: A�a� lf,:�.�N �f((A rt�A (t91{� ` • 'fP"`
ie)_la,Z,'sti<�{..1' =- t414 }xiNl.<tj�1.,{!,4 tl tiRd3 `13j
`:i`r�di�fr�f�tfi:,�;rii>J:463t:°,fT� 3f1t f#alf3?",1 .fySifil �i� M�
-�
i� sin.;F,l; ''4�G�t`� tit • ii1S�-5 ".�� y, ➢ �{ atif
;��n. I)f'��1.�;-'�?�li �g�f.��.��)�)-•e..t'`.�-�;1� �C?�91o�9
<
Taa'\$T'J i`+t�:�ru Pt�,FiW��f'•t.-_r`�Yw Qf!fJ�`'�iD4t
Y!Yi'1'4�' AI e'tI�`•;,i01i(°'f'6ftAo:c +1)1)iAN, ZY9:1
Y �?(''(( (•'yam " Yl A � u _F°
�'•', C:. e h`fa
v �'t',%, u'►l 1, VDF°F,
,q
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
r
4
m -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings -
p
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
3 r/c� 9
Exhaust Fans
O.K to Wrap
Framing
_* - Oo
_3�. Oc7 �.b _
F.A.U.
Compressor
Insulation
y— 7 - Ov
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath�—
Drywall - Int. Lath
y — ! 3 c4 �p
Final
Final `'77
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backsi
-pv
Electric Bond
Footings
Main Drain
Bond Beam
Ln� �9
Approval to Cover
_
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
_
1Z
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
ZU -z";-_j
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) -
COMMENTS:
BOX 1504
Building -495 CALLE TAMPICO A P tP1 NLY
78
Address a1SC---,LA QUINTA, CALIFORNIA 92253
uwne, C a j
V,
Mailing
Address 51 Aie— Ca-yvic."te,
City Zip Tel.
LCL� C� t'J.IVX+41
Contractor %
Address
City
State Lic. City
& Classif. I Lic. #
Arcn., tngr,,
Designer
Address —FTel.
City Zip State
I I Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereb affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of tivision 3 of the Business and Professions Code, and my licen as 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.Susiness and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior fo*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 (S500).
C] I as owner of the property, or my employees with wages as their sole compensation, will
do ihe 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 'hat 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.)
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 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 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
Works r's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n 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 it the permit is for one hundred dollars ($100) valuation
or less.) .
I certify that in the performance of thp work for which this permit is issued, I shall not
employ any pers 0 n i . n 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 it 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.
�ignature of a0plicant —Date
Mailing Address
City. State, Zip
JILDING: TYPE'CONST.—OCC. GRP.
P. Number 110 - V'RI4 CoR _3
�gal Description 61y/
oject Description
Sq. Ft. No. No. Dw.
Size Stories Units
New 0 Add 0 Alter 0 Repair 0 Demolition 0
valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
M ch.
Electrical
Plumbing
S.M.l.
Grading
Driveway Enc.
Infrastructure
TOTAL
AMOUNT
REMARKS'
ZONE: BY:
Minimum Setback Distances:
Front Setback from Ce teb I-*
n�
R
R
Rear Setback fro Fr,�
kc fr
Side Street Setbac frP�enterl_ine
Side Setback fro
FINAL DATE INSPECTOR
Issued by: A`-1-JNTb
ermit; 1
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 12/28/99
No. 19854
Owner NameJack Clark, Jr.
No. 53-365
City La Quinta
Tract #
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515 ^
CERTIFICATE OF COMPLIANCE
APN # 774-084-018
Jurisdiction La Quinta
Street Avenida Velasco
Lot #
Type of Development Single Family Residence
Comments
Permit #
Log #
Zip 92253 Study Area
Square Footage 1506
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 1,506 or $ 2,906.58 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/Valley Independent Bank/Jack Clark, Jr. Telephon¢;-�60:564-3511
v
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Olivia Aguirre
Signature
i' •: `: �u
� �, Y � L
.f�. ±~
Payment Received ,u, -$2;906,58`
Check No. 20950 5
%
NOTICE: Pursuant of Asrsembly Bill 3081 (CHAP 649, 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
0RA14'GE C0AS!T TITLE CO.
RECORDING REQUESTED BY: '
ORANGE COAST TITLE COMPACOMPANY
99.8444KC R-17459.6-.1
WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN"BELOW,•
MAIL'TAX STATEMENTS TO:
JACK L. CLARK, JR.
54-350 AVENIDA HERRERA
LA QUINTA,.CALIFORNIA 92253
Dod. Translec Tax
Riv Co. Recorder
SPACE ABOVE
09'7390
S ell
RECEIVED FOR RECORD
AT 8:00 AM
MAR 10 1999r
eRhra�rslde CMU M R�ooida
�c. >a
Recorder r .
p
4
Fees $�e��
i
'HIS LINE FOR RECORDER'S USE /
VKPN: 7745084?Of8S3�
..- .._ RANT DEED, - ._
The. undersigned grantor(q) declare-
Documentary transfer .tax is $11..55
(XXX) Computed on full value ofp.roerty,conveyed, or.
( ) Computed on full value., ic_.ss liens and Ciicudibz`ancrs remaining at time of sale.
( ) Unincorporated area: ( �) City of ,-and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged;
`•- LITTLE COMPANY OF MARY HOSPITAL,.
`�J '
hereby GRANT(S) to
JACK L. 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 7 IN BLOCK 226 OF UNIT NO.. 21 OF SANTA CARMELITA AT VALE LA QUINTA, AS
SHOWN BY MAP ON FILE IN :BOOK 20 PAGE 22 OF MAPS, RECORDS OF RIVERSIDE COUNTY,
CALIFORNIA
Dated February 10, 1999
State of California
Count, of }. S.S.
On /c!
before e,
personally appeared
Ronald : S . Guz iak
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/theirauthorized.capacity(ies), and
that by his 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 of.ficia seal/;,
Signature
MAIL TAX STATEMENTS -TO: SAME AS above.
s
LITTLE COMPANY OF MARY HOSPITAL
BYGrtil
Name/Title
BY
Name/Title
KAREN L. DE PRIEST
�+ Commission # 1153968 Z
< .a�-
Z -a Notary Public - California
Los Angeles County_
My Comm. yes Aug 31, 2001
(This area for official notarial seal)
,
:5
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, JR.
PROJECT
ADDRESS: 53-365 Avenida Velasco
APN:
774-084-018
LEGAL: LOT � 7 , BLOCK 22.6 , UNIT 21�, S.C. @ V.L.Q.
C D BY: Leslie Mouri uand
BIN NO:. CASE NO. 99-92 ..CHECK -DATE: -.
10 194h'�
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 ,
vn•....,w:: v: v.•....., .. v•:; ••: n}•;: .,}•••}}:C: .....: ..nvx: L'i:.:4:n} ': ..}\w`:{
:{;:y`: •\:iLS+:\}}:t\'v �h:\•): \::\t\'\{` •�•k•: :. \..: •C :;.k• {'v: }f•v\, <U•}.$,C\,p�;}�: n+^f \...•.:: �'}i>•}+Lv:.\•: :�
1♦\v:v,:. .:\4}\}:•}::vxvn \... ::ti5 :n \••::'p, ti: •`•; •};\..}� *`, ::�.:v •`:\::}}`: n}$}L>N,.i:�. •. \ ��
i'x{ti\;•:is•.}::5.\\.}.:v,:N'•$:\::{}•.t�: •4r\.ti:X. .v::l v.:��ti±iii::U�`+•\`QZ�: Kq:'`.kk: �:}{;•.:i?i`�ti: :yi:. a{?•}���"\`: •.. `�
}Y\*': \Z,w;,$}.}: 4n}\.`\�,.:: �`fi�:vii?}.:}}�v}:i�::i}�:\\\\�ni�:}}{'i.'n \:h;i:;`W::}`\•,�v�;$:ti�,
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)
7—,58 7
Con" istericy-with-street/surrounding area:. `
Colors
Materials
Architecture
D
e
'
OTHER REQUIREMENTS:!
. ,
�� ULA" •
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 1ile.
CITY. OF�.LA QUINTA SUB -CONTRACTOR •LIST
`rJOB ADDRESS_' ___. _..,._ . _ PERMIT NUMBER _ OWNER_ i BUILDER'
This orm shall be posted on the job .with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work', Failure to comply will result in a stoppage, of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by appl+cant. "On File' is not acceptable response.
.. .. .. .. .... - .. ..:....:..... ... . .... .n . .. . .. ... . ....
e ::::.}.::,....., tilrorkers.Com ensa4inn:insurance.n.....:.:......:::..:.:.:::k:.,:":::::;;;'•`s:�.:.Busrnessllsepe::'•:IClassiticat ion}..'..• ..............::Contracibr:.:.:....::':..:.::..;'•.::.•.::.:�}..:•':•.:::.....Staig�Contreolor...s11c. rts.�..,._ ...:;;.,:..':: .'..: •..:.. P '
` Company Name Classification lScense Number ,Exp. pate Carrier Narne policy Number Exp. Date license Number Exp.'Dete
::...:••:.:.':....:: ro .. a R C_RI rfYYYYYI . ITYfYYIYYi le_n. Strate Fund. CalCOmni {Format Varies) 1>ixlxxlxxl txxxxi Ix 1 lxxl
RK
r�t..O t2>r5 �Q1•L� I t3
� l
� � 000 5
I -3
pt_�lcN Le ..NW
ItcG
C51.1.80 33010
.EARTH
A i' Ni COc1My6"04 _ �
� . C.IQ
t r%�i-(p! `
Z-29- 00
M tQ cet-XTQlf l
(V 1-0-22 4 9 3-
I
,.
CONCRETE'> C 3"<`
T
3�o1p 3g5
t+ 30 00
C ,ojL-QEts EAeL-e`
NW C 3404.63
FRA6giNG:1.C.;��.;. ;.:
A i' Ni COc1My6"04 _ �
� . C.IQ
t r%�i-(p! `
Z-29- 00
M tQ cet-XTQlf l
(V 1-0-22 4 9 3-
� STRI)C7;;5'rEEI�[C_51>}`�';°.
,.
- _
.•
�
-
-
.' n
PLUMBING: iG=36j
M . 4'A LV IV
C-,5
l t{-
T 31
STs�T G
X
13
` o
....
IATN; f?I,AS7FR tC-351
`�-
MA trtAYbJAl:l
Oiri lo�
0O�1Z
-Y
_
1rt>r
A �,s E'f'T�
C2 t C
1-1-5124
ReMantT 1t.rDEa►►. .o
wN48-(s3�b'ii -04:
to -6
► 80 •
1-_N •o ..
:.:;.
` s '�
t1itAC IC zoy : ,
E.
c 2e %�
�-g S 9 fob,
3 31
- is�atJ >\i�i�t iiNllL`�:
C',>, 2z.
O;�t'kM 000 l'212.
,, r=51i
POP,
}I
- c .. z�:-5
�
EtEC�RICAL l!1✓ �Uf. ?> -
'�
�i l �'
'74-8 !
/ o
y 3
L.tFa2Nla tNbtrMx
�.f�Vc�ti+9'71-7� K
e
oil t -i 0
- --
0 at'gx
-
`.�.�
'
ooFwc lc as `
a ,;
;......:..
�..
�. A '� `F-
p
39
�I
' 4: Vd. rRGr
`toffs s f�;1�iLts40
S
'�o.�g
- t 2a x
a
t�s�i9 -
SHEta METAL IG -3j
.
:GLAZING tC '171 " ° _:
�
f�.i • W i�.t r3a Q.11S . 1C
g C ! `
k
...
<N
Tek�.
sl "38 ! 2
9 0
G loll
Wtt 0691-i�tl-
_
SE'IAIA,�CGIEIISP(C,21�`'
-
:.PAINTINGV
P
3�9
a, 010i�
Z� o/
w�G
o J. q� D(5138�
DIo IZb
l�
pll� D�
CERAMIC;<711[: f=s
�'
C1461NETS, iG' 6�>? ,.Y . r
it It.
F
'.l
..t>•t:i'fS..'x• y�:.a.:k?<Yy •$:•:ie �?—
4 AY -9q
�
-�'7'i £s
l
City Quinta
of La-
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: 53-365 AVENIDA VELASCO
Use Classification: SFD Bldg. Permit No.:. 9907-101
Occupancy Group: R 3 Type of Construction: VNN Land Use Zone: RC
- Owner of Building: JACK CLARK JR. "Address: ; 51-220 AVENIDA CARRANZA
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 06-20-00
Building Official
POST IN A CONSPICUOUS PLACE