0303-236, 0301-156 (SFD)C
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LICENSED CONTRACTOR DECLARATION
it 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
811 U 4 B
A
i �rti
Date a 4z. }Signature of Contractor•" -
V 6 X f
t OWNER-BUILDER•DECLARATIOkAN'
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 prope'ft i am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
() I am exempt under Section, , B&RC. for this reason
Date Signature'] of Owner
` WORKER'S COMPENSATION DECLARATION
I hereby, affirm under penaltyhoyperjury one of the following declarations:
() I have and will maintain la/certificate of consent to self -insure for workers'
,n
compensation, as provided for .vb Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(,j) I have and will maintain workers' compensation insurance, as required by
Sea`tlon 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 �'� L' Policy No. Rm Ixqso
(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 Section',3700 of the Labor
<< f;
Code, I shall forthwith comply with thosef prowslong5/"{ 9
vrbate: ' '"' 6.�'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 tokancellation.
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 (Owner/Agent) / �} ° _''�/+``'� Date
BUILDING PERMIT PERMIT#
^ 0303-9«36
DATE VALUATION„ LOT �Y," . TRACT
JOB SITE
ADDR SS :52-+0.1,:S .A,�VENJr � �� t! ...
APN y'�..;r'-.�,11-0,611 2
OWNER
CONTRACTOR / DESIGNER / EN (NEER
KC
1Z:.C., DTNT1. LOp7eEW
SO -145 VID- TAGHWI3 E
R9-10 VITTACRIVIT,
LA QiJLM'A CA- 1.92253
LA (,!UINTA C",ls, 302253
- t
(76G)578-0325 {,` 3 *
USE OF PERMIT
16X5 SY SIKL. k#F.RM1T 'b0ZS i,F'. T iN4:ff�k: F7L J�:.�` T✓V��. F, 2� . �� � ;,
r
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TatA,t;'1' Ct N.'fir�tJCi1 1�5;.3.40 ci�,v`
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:PC��.irtIrt�AV0 � iia.tlOS1 ®w!
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17
Evnlyit 7.',11:6. COST 010 CO,NS'!`lv?rmmlCb.4►#'::d„if)
{:Ci��a'a��t:'I'JC1N ��7• �fl1�>:iClf;�.�i���tifl 30��,',��
{
x}i. UP CHVIK FNS 152350
11ILtl: _Ht".p7i 1A.L MP, 1 a 3-000-411•"E!{)fl
T"i.iSM%1WO 088 100 -VX419-000
9MONO� � *100 F0.9 - PT-5JD 1 fl3.000.241-000
�6iii�;a•€� 1�`�F:. '
Lhl;'•drEi aiPFR IMPACf Piny SMOS.00
PR'ECXS E PLAN T ra 1-fll�fl�kb 1- �d3 � 6a�iJ. f.+it
iVUT - 1,YfAi1.. C'0=:fi►.3L"x; ON AND k'.1.d tT CHFICK
,R•W.A L MVIArd :C KES DUR, NOW
�i�7'_{•0.`�h�,�
RECEIPT
DATE
BY
DATf FIW.ED „//'
INSP OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
5-t-03 1z
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
-03 L.IC 61 $
Exhaust Fans
O.K. to Wrap.
G, - 7.0-p elf
F.A.U.
Framing
./�j �G
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
Underground Pi . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-03„ f3
Heater Final
.Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
`
Gas Piping
y
Gas Test
15O
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:
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
a19 3$1, 311zt
1
DAB ^ �' `�ySignatureof Contractorf/
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.44.,.Business & Professionals Code).
( ) I, a ,owner of the property? am exclusively contracting with licensed
contractorVo construct the project (Sec. 7044, Business & Professionals
Code).
() I am exejnpt under Section B&P.C. for this reason
Date ;�� Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affm under penalty of perjury one of the following declarations:
() I have"4nd will maintain;a certificate of consent to self -insure for workers'
compensation,ya-�ovided 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 ST.ATZ FI1�0 Policy No. :58413900
,• Y
(This section need not'be completed,if the permit valuation is for, $100.00 or less).
() I certify that in tie performance of the work for which this permit is issue
I shall not employ any person in any manner so as to become subject to e
workers' compensation laws of California, and agree that if I shoulrL
me
subject to, the workers' compensation rovisions of Section 3700 or
Code, I shall f "rthwith comply with those peov'
Date- Applicant �✓ i `'
Warnin��q: }Failure to secure Workers' o pen A ion c rag unlawful and
shall subject an employer to criminal penalties a fines up $100,000, in
addition to the cost of compens damages vided for Section 3706
of the Labor Code, interest and attor 's fe . ,A
,t
IMPORTANT pplicatio ma the Director a
fora permit ubject
he co ons restrictions
application.
JOB SITE
1. Each pers. up
Mnd
wh , ehalf t 's applica is made tse
reques - nd
ose benef' ork is pertormed unnt tan
mit iss
result of thi pplicaton agrees to, nify&
hol mle a
ity of La Q ta, its officers, agents.2.
Any pe ss
as resu this application becomoi
work im
ced n 180 days from date of issuance of such
per ' , or cessa -
• work for 180 days will subject permit to cancellation.
Ify that I have rears application and state that the above information is
c rrect. 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 properly,fo�rr inspection purposes.
Signature (Owner/Agent) + ?7�?-!r,1 Date 1A
9.,
BUILDING PERMIT PERMIT#
*�:
/ TRACT #
DATE VALUATION LOTS
$111,�33A0 1 MIK 5
JOB SITE
APN
ADDRESS 52-015 hEWl'1'71fDA 7MAZ
7T4 -2i 1-€212
OWNER CONTRACTOR'/DESIGNER / EN (NEER
KC DE*_7,0PhLax' f3i3F��ratg31��3j+ti y:
a 80-345
k3y'Di' BY►JitdW�rid:•
80-145
LAQt.UINTA "CA ?2233 1.AQU1WA CA 92253
(ltii7 57 X25 C13LO
USE OF PERMIT
JAM
inism ,.AKisF'MMs7';M ?S11OTfrac lV . LOCX' AW, yc:t.r
1, % CT_ e ` �c `100 I,SF 1 13F
C1 Sy
Y
p
i
.1 cogropcoMVI—RUCTION
111P33.40
gc���•rF ��rtf;�� �*�. 1���c�aol�a��ooa sp��,3s�
°$56A.06
P
!
F „t2E.1' Sl` 101.000.439.318 4250100
tVt9C 101 4*0-421-100 $59.09
EirECTiti� L FIT ' 101,000-420-000 $122,91
�
' 1rtt:, ,;� , y ` -1 U ! •at,70-� 19-t2t'7ti `1y 2;.x3
pLiJ.
itt Vt7 ttE: RMik3 101-000-13.000 811,2:2
t 0 "-..F 101-000-423-000
"OPE€t ,Cl -PACT FEE
a�Pl:Ata 101-f1t'041W?s�iS
SUATOTAL COMM :iMON AND PLAIZ e_,'MCK.
$4,08,4.83
Ims PRE -F AW+. jILI's
��
42,,50,00
D 3
r,��+;ralsa.rt?:.r40W,r
E i
[4 AR U 3 2003
CITY OF LA QUINTA
FIHANC'F [)E_ PT.
RECEIPT
DATE / rr
BY
DATE FINALED
INSPECTOR -
INSPECTION RECORD
OPERATION
DATE
- INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVA
Set Backs
e/
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 Aft
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
AWR
Fin
Final
BLOCKWALL APPROVALS
OLS.- SPAS
steel
Set Backs
I c Bon
Footings
n Drain WE
Bond Beam
4�
pproval to ove
EquipmentTocation
L1ndqAjbQnd Electric
Undo Plbg. Test
Final
ing
PLUMBING APPROVALS
Final
WH�er
Waste Lines
��
inal
Water Piping
bing Final
Plumbing Top Out
`
ipment Enclosure
Shower Pans
Sewer Lateral
. for Finish Plaster
Cover
Sewer Connection
Encapsulation
Gas Piping
_
_
Gas Test
Appliances
_
Af
Final
Utility Notice (Gas)
AL APPR ALS
Temp. Power Poll
Underground o
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Race cles
G.F.I. Af
Smoke D . tors
Temp. of Power
F' 1
Utility Notice (Perm)
Final
COMMENTS:
To Permanent File
52-015 Avenida Diaz — Single Family Dwelling
KC Development (Stan: 578-0325)
7/2/03
• Original permit #0301-156 issued in error (1886 s.f. house too large for corner
lot) on 3/3/03.
• Error not discovered until first field inspection.
• Applicant submitted revised (smaller) plan for plan check.
• Revised plan approved 4/7/03.
• Refund and revised (1613 s.f.) approved plans issued to applicant.
• Paperwork misplaced until 7/2/03.
• Applicant signed new permit #0303-236 on 7/2/03.
12'03
1011�M�-� 0301-156 T)ELCJZ3> P2&0,. -.&%�� sgOAZZ
9" ?N°3
4#%VIED 0
S -Yo
w gR"O'ouNEs'- Desert Sands Unified School District
RANCHO MIRAGE 0
i INDIAN wEus a 47-950 Dune Palms Road • La Quinta. California 92253 • Q6 ) 777-4200
• P"MDESERT ti _91,-V7
�� �_ } �A (1I )jrqTA
LA ouINTA .�
''p iNo10 yp
• MAY 13 RECD
May 7, 2003
Mr. Stan Kozloff
KC Development
80145 Vista Grande
La Quinta CA 92253
RE: Developer Fee Refund for reduction of square footage a 52015 Avenida Diaz
La Quinta
Dear Mr. Kozloff,
Please find : enclosed a check for $584.22, warrant #14473723, which is a refund on
develope ,fees paid on the residence at 52015 Avenida Diaz in La Quinta.
Originally, we received payment from you March 3, 2003 for 1,886 sf, which totaled
$4,036.04. We were later notified by the City of La Quinta that the size of this home
must be reduced to 1,613 sf because of the lot size limitations. Based on our fee of $2.14
per square foot, and the remaining balance of 273 sf, the refund paid to you is in the
amount of $584.22.
Enclosed is revised certificate of compliance #24195 for your reference.
If any questions, please contact Sharon McGilvrey at 760/ 771.8515.
Respectfully,
. �qvr��
Peggy°Reyeg;- ; .
Facilitie§Director. -.
Enc. .
PR/ sm
CC: City of La Quinta, Building & Safety 1
CERTIFICATE OF COMPLIANCE J��FI�sc
Desert Sands Unified School District z �o
47950 Dune Palms Road
BERMUDA OUNES
CHO
Date 3/3/03 La Quinta, CA 92253 RNDIAN WELLSE
No. 241955 (760) 771-8515 �dVi PLA OUINTAT
INDIO `�
Owner
KC Development
APN #
773-211-012
Address
80145 Vista Grande
Jurisdiction
La Quinta
City
La Quinta Zip 92253
Permit #
0301-156
Tract #
Blk 5
Study Area
Type
Single Family Residence
No. of Units
1
Lot # No. Street
S.F.
Lot # No.
Street S.F.
Unit 1 1
52015 Avenida Diaz
1886 Unit 6
Unit 2
Unit 7
Unit 3
Unit 8
Unit 4
Unit 9
Unit 5
Unit 10
Comments Cert #24195, 24196 and 24197 combined on CC #406657810
Direct Payment issued on 4/08/03 -for $584.22 as residence reduced to 1613sf.
At the present time, the Desert Sands Unified School District does not colied fees on garages/carports, covered patios/walkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 1,886 S.F. or $4,036.04 have been paid for 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/Bank of America - Stan Kozloff Check No. 406657810
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Sharon McGilvrey $4,036.04 0.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), 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 issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the Distrid('s) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building DepartmentlApplicant Copy - Applicant/Receipt Copy Accounting
To Permanerit.File
52-015 Avenida Diaz - Single Family Dwelling
KC Development (Stan: 578-0325)
7/2/03
• Original permit #0301-156 issued in error (1886 s.f. house too large for corner
lot) on 3/3/03.
• Error not discovered until first field inspection.
• Applicant submitted revised (smaller) plan for plan check.
• Revised plan approved 4/7/03.
• Refund and revised (1613 s.f.) approved plans issued to applicant.
• Paperwork misplaced until 7/2/03.
• Applicant signed new permit #0303-236 on 7/2/03.
1/4/03
Progressive Insulation and Windows
9750 Topanga Canyon Blvd.
Chatsworth,CA 91311
(818) 709-0988
Fax (818) 709-1088
License Number 418046-C2/C17
Insulation Certificate
WORK AREA
Exterior Ceiling
Exterior Walls
Kneewalls
Walls Sep. Garage/Living Area
Radiant Barriers @ Gable Ends
Draft Stop
Title 24 Caulking
Customer : KC Development
Job Number: 102326
Job Address KC52-015
52-015 Avenida Diaz
Revised Bid
Date Completed-:- —31-03
03
Progressive Insulation and Windows
Builder Signature:
ITEM INSTALLED
° R-38 Unfaced Batt Insulation
R-13 Unfaced Batt Insulation
R-13 Kraft Faced Batt Insulation
R-13 Unfaced Batt Insulation
Aluma-Foil Radiant Barriers
R-7 Unfaced Batt Insulation
Windows, Doors, Base Plates, Plumbing & Electrical Penetrations
Date: