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0202-101 (SFD)LICENSED CONTRACTOR DECLARATION 1 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 Licenseds in full force and effect. License # Lic. Classy Exp. Date/ sw,,. 111 d l' I � Date � �� Signature of Cont—,.•-�'l „ 5 , OWNER -BUILDER DECLARATION ;I hereby affirm under penalty of perjury that I am exempt from the Contractor's 'fLicense 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' bf 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: Carrier STAT11 FUND Policy No. 046-01-0010426 (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 ,ectioe-73�Qof the Labor Code, r1 sh II forthwith comply*wlth•t ose proves on d_ Date - fl, Applicant•! C , Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for imSection 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth o6 his application. z 1. Each person upon whose behalf this application is made & each persori at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2.'Any permit issued as a result of this application becomes null and void if. work is not commenced within 180 days from date of issuance of uch permit, or cessation of work for 180 days will subject permit to candel4s�tj�on. I certify that I have read this application and state that the above inforl correct. I agree to comply with all City, and State laws relating to the construction; and hereby authorize representatives of this City to en the above-mentioned property for.,inspection purp s Signature (Owner/Agent)'__,? Date f+ _.. �� .. PERMIT # F BUILOING:PERMIT DATE VALUATION.'., LOT'. TRACT i10811101 a. BYIX x381121.: JOB SITE APN ADDRESS 53-817SAWMA V;i3.•I.aASC:O ', 774-164- OWNER CONTRACTOR/DESIGNER/EN (NEER 1860 MCA00 AVESUITE 04 ? 7401ZiP1'IMM"MM,1l+.iOlei?NO VAT2EY CA 92507 RMIR°xID (14A 92508 (909)485-8033 '6123 USE OF PERMIT WNCLG Tp MY DyEL, NO SFDIY'EMT 0095 2V'OT 1p1CLUDE BLOCK VMLI,, lYWL 0R 1)RJ ww%7AY APPROACH, 9$ MA;3 RR MALIBU, TRACT CONSTRUCTION 8F POIiC'ki/PATIO 10.00 SP' # 0ARAMMUORPORT 4421,44 ..0 5 8r'. WOOD FENCE b? ESTT1� c:Off OF CONSTRUM014 108,10120 .. Rmwr ' ITS 94TA04ARY hi IV.31AMCAL FEE 101-000-421-000 0210 ELECTRICAL FEE 101-000-420-,000 MOM MUM± BINO M 101.000.419.000 V21-6 STRONG NOTION M • R SID 101-000-241-000 $10:39 MU MING FUle 101-000.423.000 $20.00 'DLLr10'i� 1A 110PACT FEE $1,907,00 PREC10F P14AN $00.€0 Ir?UVI CHECY, Y y $3 i -©04A4 9• 113 $436.15 C ONOTi2UC11014 FEE 101.000-418-800 $671.00 nip DEPOaMI i �9$ Ot~l0dS39- � l f1 <$� 10.ib(3 SM -TC -MAL COM.' iRUC1 tOM ARD 1-1,P r ri�� MCK $3,,450.63 LE.0 M -PAM Mei 4250,00 .�TMAL PERMT31M, S DUE NOW e, lJ U y � DAT By' DATE FINALEDD INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Slab Grade Ducts Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap te F.A.U. Framing 402/ Compressor Insulation o y 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 ZS o POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs 3 O Z 3 T 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 �01 15 .i Heater Final Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral- Sewer Connection XT Pool Cover Encapsulation Gas Piping Gas Test S - O Z ,� lot - 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) e;C- -1.2.p Z ' '��rer#Fa_4gT t r� r f �11Y1 ; P-A--'F."`i' BOX 1504 Building ���R ! 78-495 CALLE TAMPICO APPLICATION ONLY AddrPcc LA QUINTA, CALIFORNIA 92253 owner IV- /Z CA! Mailing /�/ - Address ��J 1, /1 e /O ress City State Lic./ L;ITy & Classif. t Ir tfy Lic. Arch., Engr., Designer Address Tel. TYPE'CONST. OCC. GRP A.P. Number "74/ — / /e 4/'"flZf) -�/� / �00 Legal Description L.Of g ac 23" U 77'''Z� r ( LL Project Description .7Fp City IZip I State I Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code, and my license 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,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 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: 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.) I I 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.) t] I am exempt under Sec. B. & P.C. for this reason ff, / Date � 7_ /} -Owner r WORKERS' COMPENSATION DECLARATION Ihereby 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. (7 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 if 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 o as to becople subj !![ to the Workers' Compensation Laws or,C li ornia. Date �L�U�- Owner NOTICE T, APPLICANT., If7after making thi�ilic��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 Ihereby 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 sof this city to enter the above. mentioned property for inspection purposes. Signature of applicant Date Mailing Address City, State, Zip Sq. Ft. Size New] No. Stories Add ❑ Alter ❑ Valuation PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS No. Dw. Units Repair ❑ Demolition ❑ AMOUNT 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 Permit Validated by: Validation: WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION 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 r Date 3/6/02 APN# 774-164-020, No. 23016. Jurisdiction . La Quinta'', W/R Enterprises ' Owner Name p , � Permit # 0202-101 No. 53875 street Avenida Velasco Log # City La Quinta . Zip 92253 Study Area •Tract # BLK238US Lot # 8 Square Footage 1788. 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 rnobilehomes. 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 2.14 X 1,788 or $ 3,826.32 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 East WEst Bank - Ed Whitson Telephone '909/779-6000 Name on the check' By Dr. Doris Wilson Superintendent r t Fee collected /exempted by Crystal Scott Payment Received x'$3,826.32 • Check No'. 2341211 Signature, OTICE: Pursuant to 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 bove 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 ollect them on the Districl:Cs)(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 SENT BY: HP LASERJET 3150; 7607732819; NOV-29-01, 1:24PM; 'PAGE 2/3 11/08/2001 15:40 -768-773-2819 AMERICAN TITLE C[' PAGE 04 eacapr•a ■raurauF a. - L AYp v.nl.. MCONV1 oft A.11 prep YES UNLESS � - O/w awlll FnpY/M Fr,i pY/. MALI q• FIO(YIMH !p `w Vir,ill J. Caton , .,• I" 480 Alpine .Road ~ orange, cA 9266E �F # L FI1 / SPACE A90VE TWIA DINE f0A'ACCOAKA'9 U9f� C!CUMfN1Mv 1RAp5/Esl TAX OUITCLAIM DEED'aalnpNlaa•nIUF.alueWproperlFAonaF•p,pl i cptnpUlod an tvn plw Isar value of INIM and ✓ {/�,' V JfWI / - encvTOgpcb Fag4Mlnp ■1 IM Was at Lal•• WILLIAM a. BURNLW AND JUDY A. BVRNET7" Ina Yrtevolpned Otanlw(a). jai A valuaFlF conelow,11 n, nacelp, pl wAkn is M1ep1 acanovrlap0ep. eon Dareor /embe, nbeu ane rot•vav OVNCWn to VIRGINIA J. BATON 1ne lalewlnp deavlpap real plopatly 10 111a City ol LR Quint a County of Riveroida But• 01 031114Mla; LATQUINTARASKPEReOlp MAP RECORDEb IN BOOK 20. PA0ACA2ppV' F MAPA IN THE OY�ICZ OP THE COUNTY RS+CORDSR 0P SAID COONlY. Mawact'• poral No. eFreulFa pa0 �. 19�i.el EE"'� gr—" . ]. as 0. Burnett 4Y WAR OF CILLIFOaM��IABurnett �� �� ) ' cOtAM1r of 2.T.Se tgor ia, - . dh ln.._� M Al 18131Air_. Y law Tau td17?wr m.. Y gaDdWn�( eAaA . 04 v.aal.rerlae. • NA11.y t1Ark o aid■ M aea Staid, watRasr AIMAraa AI■ar• aaaaa1001Mh� pdelr W ^aAwrI�–etc ilt ✓s,.A' AIYY11aO6 . •-•.��--....... _.—.w w oel.t. aw.Avo Iti Yb..1 ai.ww? bra..t.! 1. aw N. aN...A MFa.. —'JI, . . Wee■leao b l4 �ehn lFurYMN. Mo.■A.wNIIVG a Fl. M,V . 1n1N�{iF RWINAM.M 40[ �1 FNM. ndaly III Aad tar We INN . MALI 1Ah l.FV em lel e1.0 ".1W 4-1 '• 91ArEMLNiitOY.Lt&jrjL1 .S).a..E&j.00...4BQ_.� W liiilr` �.I. •w V �� .��. •.. w. ' ORDER# prop:cRimside: Lot 20 o - RV: 1992 00137650 11/08/2001 03:28 PM 1 of 1 f 0 SENT BY: HP LASERJET 3150; 7607732819; NOV=29-01 •1:24PM; PAGE 3/3 11/08/2001 15:40 760-773-2819 AMERICAN TITLE CC- PAGE 03 «www� NICp1Y0 r... 10 + • �~ 101537 a.. bonald k1a�n, EfQ. • .2327 Horth tiro. dray, 1940 �• Unta Ana, CA 92106 riECE1VEDFOR RECORD _.._..— 4rwor Aaova roup uaf roa macpnowe•a uac rr wW N•Arw1 w) . papa. r —i W1AR 2 i 1Ehf a,. VirgInis J. Eaten papa,. 460 Alp/n. Road � W Orknge, CA 92468 ft L_ Y' ORDER# prop:QRiverside: Lot 20 0. RV:1 "6 00101537 11/08/2001 03:28 PM 1 of.1 ORDER# prop:QRiverside: Lot 20 0. RV:1 "6 00101537 11/08/2001 03:28 PM 1 of.1 ' 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 per Section 9.50.090 of the Zoning Code. Its purpose is to determine: 1) that the proposed house design does not duplicate the same architectural style of any house within 200 feet of the applicant, and/or 2) if there is a need for the applicant to file for Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please transmitted this information to the Building and Safety Department as part of your correction list. Please attach additional explanations as necessary. A' APPLICANT WR Enterprises - Shevi tGki -cemst-r„nti on SITE ADDRESS 53-875 Avenida Velasco APN 774 _ 164 020 CASE NO.: 2002-614 -LEGAL: LOT 0 BLOCK 23 8 UNIT 2Z S.C.@V.L.Q. 'CHECK AND APPROVED BY: Wally Nesbit DATE: Inform the assigned Building plan checker rupon your assignment to this case. The CDD Executive Secretary maintains a log book to track applications and assign case numbers. Y. REQUIRED ITEM Y N COMMENT/CORRECTION Verify legal and APN information Consistent with MDG on file (as applicable MDG filing required (5 filings since 9/3/98) Architectural variety within 200 feet.of the surrounding area: Colors Materials Architectural design features r/ ww ,- '`03� �'� " y Apipr:o:v�Z Other Requirements: .D Planning Cornmissiloi.,..,.,r. O City Council Acomm�O initials...... Case No: c- Exhibit Depoz ,.,.......� o� oz •'- 02 2 .......�..�•, ....�,..,. «.,.....,�,,. .�.,...,. .�......,�. Al ifi ate of OccupancyCert c Cit-of La -Quinta'F y. Building and Safety Department`- S� 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: 53-875 AVENIDA VELASCO Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0202-1-01 Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC -Owner of Building: DEREK LEE SHEVITSKI Address: 9740 RIPPLENECK DR. City: `MORENO VALLEY, CA 92508 By: RICHARD KIRKLAND - (b Date: 07-25-02 Building Official POST IN A CONSPICUOUS PLACE I