9909-180 (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
31 A
Date ,/% Signature of Contrto� /��'F'' a'%" 9 i!
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..
( ) 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.
`',TATE'iY:6i? igra `+11 �Jv
(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,
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
Code, I shall forthwith comply with t, ose pisio s�
b'ate.: •Z 'Xal- Applicant's . _✓. / ; ,3 - �'
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 applicator 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 inspectionu po des.
Signature (Owner/Agent" )f^✓% Date�l'. '
BUILDING PERMIT PERMIT# .
DATEtp q VALUATION S,, 1x7197." LOT f? TRACT 81,QIJ2
JOB SITL
ADDRESS 11-8?? C'%1i,8.,d�.iEt.i3l�"s�at�, APN6��a4-wD.d�
OWNER I CONTRACTOR / DESIGNER / ENGINEER
D'trA.ti"t.: se��✓t i iL4A4 .�i.,4..rU,
t?rlLM DES!?; I' CA 9A260
USE OF PERMIT
MtNULfl :FAA-4P,'.Y 0WJA,1,.iNU
talArr,a.r
('1 _.t� tvt Sl,MY ,L4 1.AJ,.•�Af.ri A Vf'1.1A 5\� 1'�a.11Y
72,170 AMB ER 87M EF F
i;1n+3�:;r3f}yri�/P C,'.�EE.h4 �3�501.
SAM 4, M0Vrtt' tCh3F_9 NOT Iid�:LUZE MOCK WAU OR XDCA..
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a
RECEIPT I DATE I I BY`,./ r. \ / I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- 7 7
Exhaust Fans
O.K. to Wrap
Framing
_ G —7
(l _
F.A.U.
Compressor
Insulation
- cse
Vents
=�'
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- l 3 /
Drywall - Int. Lath
G
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
9
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
Heater Final
Water Piping
-ZO
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
.% ► (Connection s(J�� �j
_/, c %pp 7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
,
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
!
Exterior Recepfacles
8
G.F.I.
Smoke Detectors
Temp. Use of Power
Final r
Utility Notice (Perm)
� ' i `s.iw`�br+,r��' 7�asavJi�: '"ice' x .�;,,� .::,���,�,y„-,,`�'�1yy�'�;riy�ts>.y(pi'iwt�,:�WT��a'.�.+.3.-iw-fc✓`a�r1+'Y�!'N$�A'
57 P.O. BOX 1504 APPLICATION ONLY
Building78-495 CALLE TAMPICO
Address (/,9s,—C6/L- T92' -IA M 4,9 LA QUINTA, CALIFORNIA 92253
Owner ,�j
/nG �ru�J �2 �� 1 �."a ~s�'° �" '�' C BUILDING: TYPE'CONST.�Sc OCC. GRP.
Mailing
Address �3 /7U , A. P. Number
City ziipy q Tela 9 aLegal DescriptionGo1u h JDG t� /,. L Q..5CJIt6Y,
Contractor Project / Project Description- 51
* Co "�.�PA r'T e!�,p o
Address
73 - / 7o 4^&_ r' Q y
fC�it/y
/'�v'as
Z�iP
Tel.
. Sre -;?7 2
State Lic.
& Classif. /J _ j
u
City
Lic. k 41
Arch., Engr.
J t
Designer��/��f✓"t"�%�emte 7/
Address
Tel.
7 a9
Crrt��
Zipp.�,
State
Lic. "e,,,ll oG
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7(X10) 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, 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 ($500).
C-1 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'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.)
0 1 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
r7 Copy is filed with the city. ❑ 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 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: 8, 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
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 Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
AUG 31 1J
Sq. Ft.
Size
No. No. DWig�q
Stories y.{ ` � OF jUnitS%AUi NIT
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
t
Plan Chk. Dep.
5() •
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: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document Cannot Be Duplicated
Date 11/30/99
No. 19675
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
i
i
Owner NamePine Mountain Real Estate Inc.
No. 51-405
City La Quinta
Street Calle Jacumba
Tract # BLK3U2 Lot # 8
Type of Development . Single Family Residence
Comments
APN # 769-115-019
Jurisdiction La Quinta
Permit # 9909-180
Log #
Zip 92253 Study Area
Square Footage 1449
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 1,449 or $ 2,796.57 the property listed above and that -building
permits and/or Certificates of Occupancy for this square footage in this proposed project may.i' w be issued
w
Fees Paid B cc/Union Bank of CA/CA Desert Construction
By Telephone 340-9844
Name on the check :•
By Dr. Doris Wilson
Superintendent `
Fee collected /exempted by Juanita Green
Signature
Payment Received $2,796.57
Check No. 6528718
NOTICE: Pursuant ot/¢ssembly 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 ru 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
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
/
DEPARTMENT OF ENVIRONMENTAL HEALTH
r
PO.RMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
,1FPLICANT. Submit this form with four copies of a SCALED plot plan (1-20 SCALE) drawn to County specifications as indicated on the attached check list.
Anon-refundable filing fee is required when the application is submitted. Check must be made payable to the Countg of,§iveside'.4Approval of this applic985
tion shall remain valid for a period not to exceed one year from date of payment. 5313r-, #�t4. £
LMS # t- 1 %Y Or i(4 ri/tX 6V 54 -- UK $214 — .01.
rson
Agent, Contractor, ContaPie,
oU -re2s
Address cityState Zip
_/_0-7 57 � Qe� ���� �2f-rA
Telephone
5689729
Owner
Address - City State Zip
Telephone
Z
Job Property A51dress r—
CityZip
U
LU cU)
Lot Size
f
;DIX 160
,Water Agence'll
,. tt� [t�'y
Use of Permit, P/P, SUP, PUP, etc.
�i/ lt�,4b�/stTr:r;,42�6E
Legal DescriptiopoeK 3
c ti
LDT L IfI� d
�tl '�
Dwelling, H�SiterPre' p etc!{t��3
y
Signature of Applica fWh1 �' 6 o Y34
Rs
Date
CHECK BOX IF REQUIRED
If any box is checked, this application shall be considered rejected until
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
the information is provided and the fee paid. Resubmittals later than 90
days after date noted below may require repayment of fees.
❑ Staff Specialist Lot Inspection Required
m
❑ Holding Tank Agreements Completed
Thomas Bros. Page Grid
Z
0
❑ Certification of Existing S.D. System Required
U
❑ WOCB Clearance Required
❑ Date Lot Inspection Completed: Initials
LU
(Attach for DOH-SAN-007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
❑ Maintenance Booklet Provided
❑Special Feasibility Boring Report Required
❑ Rereview Required Initials Date
❑ Final Inspection by Department of Environmental Health is required..,'f
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Lic/Project # Date
-�-j^'
Soils Map Page / Soil Type ._-,L S Approved By Date
No of Systems
T pe o aSystem(s)
�]Piolding Tank EJReplacement
ONew ❑Addition
No. Dwelling Units 1),444
Bedrooms, Rx{lklits
(1) Septic Tank
Soil Rate
Greagge/Sannd
Grease I,ntcp/ 'nt Trap
❑ Existing
/
DODO Gal.
�t(Ij7 gal.
Sq�Ft.
Both Area
To Linear
Ft.
Sidewall AIT wance
ft. ro sq. ft. running.ft.
Install L`( ft. long ft. wide with
Leach Bed sq. ft. of
Bo Area
Inlet Tested Depth ❑ NA_
min. inches below drainlines or
U
Proposed Bottom Tested Depth
Z
0
H
Leach lines/bed special design for slope:
\
Applicable \
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Total Depth
,
Maximum
Allowable
Depth
Other:
Q
I
LU
N/A Overburden
TD
'
Well Review Approved: SIGNATURE Date: Well Drilling Permit #
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: ' Date:
Plan Check Only Approved: �f Date/
REMARKS: i�/i►ti �/�f/t .G9�0%/i�Y `�L✓Vi /.[1e1/.lftJtir+.
A�
This application i APPds R V NIED'cfor th"e�oateg" o"ry hecked;in�5ECT10N.8.
, FOR OFFICE USE ONLY
i
above, regarding the es on of a subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
ing is necessary for the installation the No
(( !� 3 �� l Q
permit of above-designed system. con.
sterctlon Is permitted In the required 1005'
Revenue code Fee $ r�• U
reserved expansion area.
t
(1) Septic Tank must beAO' inimum from any wells.0 0i"".%' rAaA_-74t-1
Check #—
d 01447-SA n area.
(2) Leach lines must be 100' minimum from any wells, including expansion area.
tP'3 0 - 9 AaL
Date Initial
_Sewer lines must be 50' minimum from any wells.
7-
0,'
Z(3)
O
(4) Seepage pits must be 150' minimum from any wells, including expansion area.
•
W
Signature of Health Official
Date
DEH -SAN -122 (Rev 9/98) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
r�P S III
ICGL l-' S � tI;"Al -�'�I`Y�� 17.81'
III
-�UJ
III III
=--- --� 4 ' III
W w
. � � III
�' III III
III - 3 I II
. � III III
-
. III I f!
COUNTY OF RIVERSIDE. HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
Food X Sewage Disposal
Trailer Park 000 Ga;. septic Tank
Motel, Apt., Hotel Sq. Ft. Ff Laachline i
-�" Dwelling 3-40Ri - /i'W}C' No. _LDia�{LBI "i�3 TD V-1 w 5ee=e Pit
Commercial Building Connection to Sawer
Swimming Pool Connect to Existing S.S.D.S.
X No on-site regenerating water softening devices may be discharged into the individual sewage disposO
system herewith approved without clearance from the Water O�alPi yPnt� 1 Board.
t1i'ater supply serQn!)MMY"Un
tallation must be from an aper a sou ce C 1lGz//
�AII sewage dispomust conform with requirements of currant Uniform Plumbing Coda.
Any cutting, grading or tilling in excess of two(2) feet will nullity so -sage disposal approval.
Approval has been obtained from the Regional Water Cluality Control Board for installation of the sewage
disposal system., '
This is to certify that the Riverside County Environmental Health Services approves 1169 subsurface sewage.
disposal, plot plan to obtain'building permit for jotalladion. construct nATE 0— By
/.
Majrl INTAl ) ANSION AREA. WN. 10 FROM A14Y WELL117b
. -
Ml 10' OM ANY TREE OR WATER MAINS •7'Y V
i 7�
_ 1°t s stank &d r+�rsr .hrtra must tea 50 fit. ki i t tj
fmm..any wdtliiir gexpansion_ aria
pts im.ist -be :250' ft mkonvzo fraotr -
,� . ,•__..��; G�o�rz�CZi� �QG �,� �1., �{ <GLc��� �2G(fL`'�(/�Cy�
J
A t \,
C n
J ACU INS BAA.'
00
Q
w R w
RECORDING REQUESTED BY:
AND WHEN RECORDED, MAIL TO:
California Desert: Construction
73-170 Amber St.
Palm Desert, CA 92.2611)
THIS SPACE FOR RECORDER'S USE ONLY
ASSESSOR'S PARCEL NO.: 769-115-019 The undersigned Grantor(s) declare that the DOCUMENT TRANSFER
TAX IS:
TITLE ORDER NO.: 507160513 $ 13.75 County $ City
xx computed on the full value of the interest of property conveyed, or
ESCROW NO.: 5298 -DS computed on the full value less the value of liens or encumbrances
remaining thereon at the time of sale.
G RArs"41T D E E D OR transfer is EXEMPT from tax for the following reason:
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Kevin J. Martin, a single man
heraby GRANT(S) to California Desert Construction , a California Corporation
all that real property situated in the City of La Quinta County of Riverside, State of California, described as:
Lot 8, Block 3, Unit 2 of The Desert Club, as per map recorded in Book 20, page 6 of Maps, in the Office of the County
R.ecorder of Riverside County.
Dated August 5, 1999
STATE OF CALIFORNIA, �
COUNTY OF S 61)t I')e rh 4 e&1; 4 J
ON Y6 us4 IDS) y`i� before me C:xt ro l 8 ural,04
Notary Public, personally appeared
Devi n Z-- m4rl-'ry
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 hls!her/their
authorized capacity(ies), and that by his/hiWtheir 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 official seal
Signatures
PAN ; J, Martin
ON --
CAROL SURNETT
Con,minlon * 1073034
Notary Public — Callfomto
San bemc:rdino County
61MV Comm. Explros Oct 17, 11999
MAIL TAX STATEMENTS TO: (This area for official notary seal)
- 73-170 Amber St., Palm Desert, CA 92260
0
•
Certificate of Occupancy
City of La Quinta
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:
Use Classification: SFD
Occupancy Group: R 3
51-405 CALLE JACUMBA
Type of Construction: VN
Bldg. Permit No.: 9909-180
Land Use Zone: RL
Owner of Building: PINE MOUNTAIN REAL ESTATE Address: 73-170 AMBER STREET
INC
City: PALM DESERT,
By: STEVE TRAXEL
Date: 06-09-00
Building Official
CA 92260