9906-075 (BLCK)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
33667 B 0_V31/26
tid/ate — r; t Signature of Contractor it 4t, G L I '
f.+ �
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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, 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.
( ) 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:
Carver Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(yj 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 iprovisions of Section 3700 of the Labor.
C deI SHAH f_o
, hwith comply with those Rrovisio : s=
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 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. .1 agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
t
hearbove-mentioned property for inspection purposes.
(Owner/Agent) f X
Dated e
BUILDING PERMIT PERMIT#
DATE f VALUATION 532%0`) LOT TRACT
JOB ADDRESS I.53-9651A�'�1�...('�IIDA� EU.SCO APN -
OWNER CONTRACTOR/DESIGNER/ENGINEER
1AC .C;l.A' ;k tiE"MRAi. CC1 3'i3tAC"IC31t JACK Chi:.E:pi .f "`3FP.� 9., CC_Y.Ad°121�`�C`'i(3I
31-220 AL'ENIDik CARil.M4ZA 51-220 ,e1V1:NIDA CAKitA:t ZA
I.4k QUWI'A CA. 92253 LA, QUIN'.FA C:A. ! 225'3
USE OF PERMIT
C NERAL isi.:fX DING
4 FF. WAU
.W.00 I
41 4TIZINI AT .4LD ir+l S T 10F �C..lii �e.SfTi aR'+ UC a 1101N a•ti► 00
PERMIT FEE SUMMARY
CONS'TRVC` ION FEE 101-000-4l "00 S15.00
S13#3-TCYrAL CONlk' `1tUGff(N .AND PLAN CH
1.Esa T'P.C-P��1L? puts SO.tf�
TOTAL PERMIT FEEN DUE NOW 11.5.00
%R DATE I DAT, t' � �w`� BY. !�DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
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
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
/
Final
Underground Pibg. Test
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
Encapsulation
Gas Piping
Gas Test
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
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 2/22/99
No. 18379
Jurisdiction
Owner NameJack Clark General Contractor
No. 53865 Street Avenida Velasco
City La Quinta zip •,92253
APN # 774-164-019
La Quinta
Permit #
Log #
Study Area
Tract # Lot # Square Footage 1,505
Type of Development Single Family. Residence
By
Comments
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 mobileficir es'..
It has been determined the above-named owner is exempt from paying school fees at this time due„to.,the following
reason:
• � ”, ate, �. /,
EXEMPTION NOT APPLICABLE c=
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 now be issued
Fees Paid By cc/Valley Independ. Bank/Jack Clark Telephone 564-3511
Name on the check
Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto
Signature
Payment Received $2,904.65
Check No. 183137
NOTICE: Pursuant of Assembly $i0 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
will begin to run from the ate on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
6LA IC -0
OLD '24 8678
RECORDING RE.QUXSTED BYE :RECEIVED FOR RECORD
OLD REPUBLIC TITLE COMPACOMPANY
97.7063KC 104765-13...:..., 4Te:00 AM .....
WHEN RECORDED MAIL THIS DEED' AM, f' :JUN. .=. 4 1998
UNLESS OTHXRWISE. SHOWN BELOW, Ti X
MAIL TAX 8TA1'EMENTS To i iMooiwa h a�,r wnnd.
'� �: J 01.IMwIdt Cw q. cdbnrt
JACK CLARK,. JR. qiv. (:^ RsoordM
';...Ire• 54-350 AVENIDA HERRERA Few$
,;,LA QUINTA, CALIFORNIA 92253:
SPACE ABOVE THIS LINE FOR RFCORDER'S USE
/D'�7GS /� GRANT DEE; AM 774-164-01.9
j T2 o7 0 o/s .
The -undersigned grantor 04Y., declares)
Documentary trpnsfer tax 'is . -$12.10
(XXX)Computedlon.full. value of property conveyed, or''T V�
Computed'on full' 'value,>less' liens and encumbrances remaining at ,time. of. sale
( :,) Unincorporated arear 'City:of• and
•'
77
( ). ,
FOR'AIVALUABLE CONS IDERATION,::.receipt. of which is hereby -acknowledged,
JANE KIERNAN, EXECUTRIX OF THE ESTATE OF•VIOLA K'. EICKMEYER'
.:hereby. GRANT
JACK CLARK, JR., .A MARRIED.,.MAN-AS HIS SOLE AND SEPARATE PROPERTY
the real property in .the City -`of LA
QUINTA, of Riverside,.Stete..of California,_
described as:
LOT •7 .IN BLOCK-238.OF SANTA.•CARMELITA 'AT VALE LA QUINTA, UNIT 22; AS. SHOWN'
�BY MAP ON FILE IN BOOK 20, PAGE 24 -OF MAPS, RECORDS OF RIVERSIDE'COUNTY,-
CALIFORNIA
Dated December 23, :1997..-;::;'.,�.:_ •.....:''::: :....:.,:.....;:: :.. .
State of Q*"4ern'ta M%(hr;an
County of -LQila r%& 1A S.S. KIERNAN, EXECUTRIX
On 3U' < <7.THE ESTATE OF VIOLA K. EICKMEYER
`'<., be f ore :.me ..ueh
Ma '
9. ally, appeared !
—lane Kiernan I
peraunaaiy anown ro me tor•provea-to me on
Che basis of satisfactory evi ence)„to be
the pereon�h�
f whose''ihame.( a are'..aubacr�bed
. _.
to the witnstrument'::and' acknowledged.; to .
me t hehey executed the -same in
his a their authorized capicityhl�, and
,:-that by his/n/their signature W4- on the
.instrument the'person(s).;;':or`the entity upon
behalf of whic)i the-person(i):: acted';, executed
the instrument: '
WITNESS my'hand and official eal.
Signature �
MAIL TAX STATZKDMS ' t .. SAME AS. ABOVE