0109-099 (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
Date 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).
( ) 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 • 41 Signature of Owrfer� '
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.
(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 issueii,
(Fall not employ any person in any manner so as to b'eeome 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 those provisions.
Date:— ! 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
ees;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. Z .
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.
Signature (OwnerlAgent)y Date •t`%�
BUILDING PERMIT' - PERMIT#
DATE VALUATION LOT ��Q;.r TRACT
PM 2703
JOB SITE v
APN
ADDRESS
e646-0.1"!0
OWNER
CONTRACTOR / DESIGNER / EN (NEER
BLA1j E & DAN'A 0.9M
Cit LR k�'.31LD"ra'2
;) Chi
USE OF PERMIT
ffiNGI I, IW f1LY IaWS Lll`I
x
s;F ! • Iwt'.1:.�i T DOM NOT t'd�YC"3: UOR fBLDCK b�A.. NS Poc)LC i,& OR
OR iVIR. AY APPROACH
j
J �• v
• 1' Y.
TRACT r..OMTRUCTION, ?,223,00 OF NAR
'
0 472002PORCHIP41MO
410,00 SP
d1ARAC PI(II'A3'1PORT WIN a' CITYOFLAQUINTA
N1����i
ES`IMA",0 COST Q ' CON MI RD'C TION
143,2,11-00
PE'RA41T IjIM SMAKA,»Y
C 01148 RUC'!1%) FEE 101-000.418-000 $ IW3130
PLKNI CHECK W1.150
FEI- DEPOSIT 101-000-439,318 425€100
MECHANICAL li T42 101-000-421-000 V5.00
ELECi'R1CAL FER 101.M-420.000 $193160
-
FI:.iYi BINK :tf#E 101-0150-419••000 $142.00
S4TRONO MOTION PRE -RUM J 0'1.0C 241.1100 $14,32
f4R.AMdCt ME $10,00
DLY&OPER IMPACT MTE � $1.907.00
SUB -54 A'Al . CCi.N:33T.Riit': ON AND Pa:.AM. C5WCR;
$3; /52.92
I.E33 %R-P.A1 f.) F—PES
42.10, 00
UYMI, PX1?A_V_V YZES DVIR P10AV
$3,502-92.
RECEIPT
DQE
BYT�
DAT NALE
INSPECTOR
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- - dzQ C
Underground Ducts
Forms & Footings
- 02
Ducts
Slab Grade
- 2 _ z
Return Air
Steel
_ _ g
Combustion Air
Roof Deck
- p - 6 Z
Exhaust Fans
O.K. to Wrap
Al, -0
F.A.U.
Framing
.. 2,1--o z JP,41 —
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 6F/
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
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 C,z
s .-C9
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
p
Encapsulation
Gas Piping
Gas Test �/
.S►` ?�
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole Z A6 sr
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) CYi p ZJ
COMMENTS:
Building q 9/-V
Address Address. b'
Owner '
I.,
_I,JP11 o V 6a17 a.
Mailing --
A.P. Number/,O J' C, - 6
Tel.
Legal Description
' f Project Description
v7 7 -C -D 7
City V V lZip I Tel.
State Lic. City
& Classif. 6 -S-/0 ;) 1- 1 Lic. #
Designer
Address Tel.
City (Zip (State
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 Contractors 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 thathe 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 rive hundred dollars (8500).
is 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, Bulsness 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 or completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
Il I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the proiect. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of properly who builds or improves thereon, and who contracts for
Such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
i7 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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 lhp 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 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.
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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
f,
APPLICATION ONLY
o1oq - o a q
OCC. GRP.
.13f,,L/
Nr QUI
" r -
x
ZONE:
BY:
Minimum Setback
Distances:
Sq. Ft. L
Size ^� �q
No.
Stories
No. Dw. 1
Units
New Add ❑
Alter ❑
Repair ❑ Demolition ❑
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by:
1L
-
Validation:
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
;=-03 O
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
Nr QUI
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
" r -
x
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 3/4/02
No. 23005
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
owner NameBlaine & Dana Osmond
No. 49-610
City La Quinta
Street Date Palm
APN # 646-070-010
Jurisdiction La Quinta
Zip 92253
Permit # 0109-099
Log #
Study Area
Tract # PM27681 Lot # POR2 Square Footage 2228
Type of Development Single Family Residence No. of Units 1
Comments
Tract Construction of SFD of 2228 sq. ft.
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
2.14 X 2,228 or $ 4,767.92 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 -Downey Savings/Blaine Osmond
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Crystal Scott
Signature
Payment Received
Check No
Telephone
$4,767.92-
05510074035
4,767.9205510074035
JOTICE: 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
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
:ollect 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
RECORDIN v REQUESTED BY:
OLD REPUBLIC TITLE CO.
AND WHEN RECORDED, MAIL TO:
Blaine Osmond
48386 Garbo Drive
Indio, CA 92211
T" o'�2 o
ASSESSOR'S PARCEL NO.: 646-070-010-6
TITLE ORDER NO.: 507648-13
ESCROW NO.: 6437 -ST
GRANT DEED
®100 N 2000-401404*
10/12/2000 MOM Eae:19.90
Pape 1 of 2 Doe T Tax Paid
Recorded in Official Records
County of Riverside
Wry L. Oreo
Assessor, County Clerk 6 Recorder
THIS SPACE FOR RECORDER'S USE ONLY
G
The undersigned Grantor(s) declare that the DOCUMENT TRANSFER
TAX IS:
$ 47.85 County $ City
_Lx computed on tho full value of the interest of property conveyed, or
_computed on the full value less the value of liens or encumbrances
remaining thereon at the time of sale..
OR transfer is EXEMPT from tax for the following reason:
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowiedged,
Charjacq, Inc, a California Corporation
By: Charles Lester
hereby GRANT(S) to Blaine L. Osmond and Dana E. Osmond, husband and wife as Joint Tenants
all that real property situated in the City of La Quinta County of Riverside, State of California, described as:
Parcel 2, of Parcel Map 27681, as shown by map on file in Book 180, pages 31 & 32, of parcel maps, Records of
Riverside County, California.
Dated September 26, 2000
STATE OF CANIA,
. . � Charjacq, Inc.
COUNTY OFi'
ON G/ f before by (
!� CheLrJ! e s �P-r
Nota Pub ic, rsonall�c 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.
WITNESS ha and official seal.
Sign �� G%Z2
MAIL TAX STATE 1ENTS TO:
Blaine Osmond - 48386 Garbo Drive, Indio, CA 92211
rA09 SHERRY F. flI AGM
COIPNnI w i 122M
Y
pRy �,,a,,,t1.1�e6 fe�i 181
(This area for official notary seal)
IW�YI��nNNI�hIII�V�II�WINd
gt
A
11
L
OPY
LONG
REFUND
NCHG
E
THIS SPACE FOR RECORDER'S USE ONLY
G
The undersigned Grantor(s) declare that the DOCUMENT TRANSFER
TAX IS:
$ 47.85 County $ City
_Lx computed on tho full value of the interest of property conveyed, or
_computed on the full value less the value of liens or encumbrances
remaining thereon at the time of sale..
OR transfer is EXEMPT from tax for the following reason:
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowiedged,
Charjacq, Inc, a California Corporation
By: Charles Lester
hereby GRANT(S) to Blaine L. Osmond and Dana E. Osmond, husband and wife as Joint Tenants
all that real property situated in the City of La Quinta County of Riverside, State of California, described as:
Parcel 2, of Parcel Map 27681, as shown by map on file in Book 180, pages 31 & 32, of parcel maps, Records of
Riverside County, California.
Dated September 26, 2000
STATE OF CANIA,
. . � Charjacq, Inc.
COUNTY OFi'
ON G/ f before by (
!� CheLrJ! e s �P-r
Nota Pub ic, rsonall�c 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.
WITNESS ha and official seal.
Sign �� G%Z2
MAIL TAX STATE 1ENTS TO:
Blaine Osmond - 48386 Garbo Drive, Indio, CA 92211
rA09 SHERRY F. flI AGM
COIPNnI w i 122M
Y
pRy �,,a,,,t1.1�e6 fe�i 181
(This area for official notary seal)
�% G/o ��f"-E� Lit- CITY OF LA QUIINTA SUB -CONTRACTOR LIST
JOB ADDRESS PERMIT NUMBER p •7 OWNER BUILDER
This form 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 o es 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 stoppa of work and/or the voidance
of building permit. I -or each applicable trade, all intormation requested below must be completed by applicant. "Un File" is not an acceptable response.
Trade /Classification
;.;.. Contractor ..:::.::
..... - .:.;State.Contractor:.s License :::....::::.
Workers-,Compensationansu�ance :::.;:.::....:. ....:::::
City Busmess.License •s
,.
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxxl
Exp. Date
(xx/xx/xx1
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
�Q
EARTHWORK ,(C-12)
MASONRY '(C-29)'
IV -14
a
CONCRETE
PLUMBING.IC 36)
V
-
-L
�3p p
FRAMING.: C=5) :::::>;: ;>?::;-;--"" .
•--
STRUCT STEEL (C 51)
N -W
MASONRY '(C-29)'
IV -14
a
PLUMBING.IC 36)
V
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S/ ��/
'
I?'��
ELECTRICAL'(C
ROOFING ......:
��-
..
SHEET METAL (C43)
Al /
OWNER / BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the -State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta 922
(7I 777
FAX: 7- 011
O ER'S SIGNATURE/DATE
y g- 6 /o Dq7?5
PROPERTY ADDRESS
Dr (99 -on
PERMIT NUMBER(s)
Certificate of Occupancy
City of La Quintal
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: SINGLE FAMILY DWELLING
Occupancy Group: R-3 Type of Construction
Owner of Building: BLAINE & DANA OSMOND
Building Official
49-610 DATE PALM
LVJ 01
Bldg. Permit No.: 0109-099
Land Use Zone: RL
Address:
By: RICHARD KIRKLAND
Date: 06-24-02
POST IN A CONSPICUOUS PLACE
BUD CA MPBEL LASSOCIA TES, INC.
431 Barstow Road
Barstow, California 92311
760/256-2976: Barstow
909/584-7233: Big Bear Lake
April 7, 2002
Mr. Blaine L. Osmond
OSMOND CONSTRUCTION CO.
48386 Garbo Dr.
Indio, CA 92201
RE: Letter of Structural Inspection
49610 Date Palm, La Quninta, CA
Dear Mr. Osmond:
This letter is to address our satisfactory Structural Inspection of the aforementioned
single family residential unit. Our inspection was performed on 4/6/02 and was
found to be in accordance with said approved plans.
• This opportunity to be of service is sincerely appreciated. Should you have any
questions please do not hesitate to contact this office.
Very truly yours,
BUD CAMP EL CIATES, INC.
B.M. "Bud" Campbell, P.E.
President
CIVIL ENGINEERING -SURVEYING -PLANNING -SOILS