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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 11 Exp. Date
Da'/e_Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Lice n a Law for the following reason:
((i) 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 this2-17, a /D -n
Date 14 Signature of Ownedt -1 ,r ` '�✓
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
pert r'mance 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 �s,.+,� Policy No.
o
(This sedtibn 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
CodP1_1 h I forthwith comply with those rovisioQp
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 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
i the above-mentioned property for.inspection puurP9. esf ,jet_
�'-pature (Owner/Agent ,itr C � t D ter' Da'te
PERMIT #
BUILDING PERMIT
"WS -20i
DATE /0. 41, f! VALUATION S1 •60 74) LOT 2's TRACT
JOB SITE
ADDRESS SiXftQ AVENIDA DLAZ
APN 774.047-i;fW
OWNER
CONTRACTOR / DESIGNER / ENGINEER
9A!.%l. aF71�. f.IAILL -
truV1f r%r )
f
USE OF PERMIT
t
S.l'ID - PF'9ief1T.lit; 9 WQT 'INC LURE �CYCK WALLS C+R is4aL
IRA, ell l,,vo.w sr�'
.
PORCi3fFi;ATIO € *AX1 SF
GARAt. ki CAR1"C. RT 47 .00 8F
5 fil WOOD r;lNCE Y0.W LF
'N S IiiNI i' . �..� S.T Off' 0DN SUMMON
CON ,r' R.fJC' ON 'FRE 101-W)419-000 VI A3,(A)
!013 ()11f)•-4�9-319 X1044 a'ti
Jpt.lT4�{T3Sf�iC�:1''3+k: i01�000-439-000
STR0'N0Y'M0TTf'P'Ed, 'RP'Siro fk6
tiu ilial 4Q # Ti,C
f0Rt-x: WU N. AN: 1tt1..CA)fti•441_3115
V-51
i { f:ltii+k'<a ilT Ii)i.fkl)li• S�? iEf{ >. 4219.) tX1
SUB -TMA f, E ONI1 ?"12UC 1100 AN 1-1 P[,}1'N aMF*C?:.
$3,470 20
RECEIPT
DATE
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
S�
F.A.U.
Framing
'57
Compressor
Insulation
(- dc� S
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—q S7—
Final
Final Q'760 7
BLOCKWALL APPIkOVALS
POOLS - SPAS
Steel
Set Backs
-Electric
IF
Bond
Footings
Z _ ci
Main Drain
Bond Beam
317 6!O 5
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
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
D 7
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:
f •
Building
Address
G3�
P.O. BOX 1504
� ,�e�"�" 44 178-495 CALLE TAMPICO APPL NY
Ll*► t de" LA QUINTA, CALIFORNIA 92253
Oner
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Mailin
Address ,�;
Contractor
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AtlOress I
1
Tel.
State Lic.
& Classif.
.�
[City
Lic. q
Arch., Engr.,
0
Designer
Address%
VV
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C°�+a\,tea.
Tel.
City
to
Zip
State
Lic. # /ills
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. 7031.5,8usiness and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior fo'ifs 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 ($500).
IJ I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
build$ or improvesthereon 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
o"f p/roving that he did not build or improve for the purpose of sale.)
Iwl, asowner 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.)
['I I am exempt under Sec. B. 8 P.C. for this reason
Date I O ner%
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. 3900, Labor Code.)
Policy No. Company
n 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 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., It, 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 deemedliev`oked.
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 tilled out, signed and validated, and is subject to
expiration it 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 adplicant —Date—
Mailing
ateMailing Address
City, State, Zip
LDING: TYPE'CONST. OCC. GRP.
Number
Description c
:t Description a ��
Sq. Ft. �/0
Size �+-
New Q _— Add ❑
Estimated
No.
No. Dw.
Alter ❑ Repair ❑ Demolition ❑
PERMIT AMOUNT
Plan Chk. Dep. 7 U
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 Sareet Setback from Center Line
Side Setback from Pro Iri
FINAL DATE INSPE TO
Issued by: Date _1A AY Perrmi
Validated by:
h
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
Date 9/20/99
No. 19332 Jurisdiction La Quinta
Owner NameMike Mitchell
No. 53-060 Street Avenida Diaz
APN # 774-042-003
City La Quinta
Tract # Lot #
Type of Development Single Family Residence
Comments
Permit #
Log #
Zip 92253 Study Area
Square Footage 1630
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 1,630 or $ 3,145.90 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 CCNIB - Mike Mitchell Telephone
Name on the check
By Dr. Doris Wilson
Superintendent �.
Fee collected /exempted by Ellen Patino Payment Received $3,145.90
Check No. 189593
Signature
40TICE: Pursuant of 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 tees or other payment identified
above will begin to run from the dale 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
a>S
M
OLD REPUBLIC TITLE CO.
RECORDING REQUESTED BY:
AND WHEN RECORDED, MAIL TO:
Michael G. Mitchell
ASSESSOR'S PARCEL NO.: 774-042-003
77Z 0Z0 -01 Jr
TITLE ORDER NO.: 116649-13
ESCROW NO.: 4668 -DS
GRANT DEED
PAID
poc. Transfer lax
549054
F ECEIVED FOR RECORD
AT 8:00 AM
DEC 18 1998
lMooslw
fAw i
Riv. Co. Recorder II ^^
W�.
THIS SPACE FOR RECORDER'S USE ONLY ' - I
The undersigned Grantor(s) declare that the DOCUMENT TRANSFER
TAX IS:
$ 14.30 County $ City
roc computed on the 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:
T
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Betty G. Kolb, Trustee of the Betty G. Kolb Trust dated May 24, 1990
hereby GRANTS) to Michael George Kitchell and Brenda Lyn Mitchell. Husband and Vife as
Joint Tenants,
all that real property situated in the City of La Quinta County of Riverside, State of California, described as:
30+31
Lot 22, Block 177, Santa Carmelita at Vale La Quinta, Unit #18, as per plat recorded in book 19 of maps, page 34, rec
ords of said County.
Dated November 6, 1998
STATE OF .ALIFCOUNTY OFF(� i ve r s i d e d� I
ON 11/17K/98 heron n1eLori Ann Doff low Betty G. K Ib, Trustee
, Metar, Public, pmmolty appeared
Betty G. Kolb
- ---- -
personaly known to me (or proved to ma on the basis of satisfactory evidence)
to be the person(s) whose names) Ware subsulbed to the within Instrument and IOQI ANN DOM
now
ackledged to me Mat he/she/they executed the carne In hOwIthelr L!a"11e>MOn a I IJIIT� _
authorized capselty(les), and that by hldMrlth*W signature(s) on the instrument N"y pry _ ComforND
the person($), of tit entity upon behalf of tit psmon(s) acted, ecuted elrerflOe Cow"
the -
the Instrument. , J mit Comm. Expses ,cure 11. =1
WITNESS my hand and oft"I&I
Spnature ✓
MAIL TAX STATEMENTS TO:
(This area to oftloiN notary aeaq
Michael G. Mitchell - 51.625 Calle Paloma, Le Quinta, CA 92253
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, in order to determine the applicability of compatibility issues or need
to require the filing of Master Design Guidelines by the applicant. It shall be transmitted to
Building & Safety as your correction list. Please attach additional explanations as necessary.
APPLICANT: MIKE MITCHELL
PROJECT 4c✓ AZ.
ADDRESS: 53=060
APN:
LEGAL: LOT ,.BLOCK UNIT , S.C. @ V.L.Q.
CK'D BY: �1c
BIN NO:. CASE NO. 99-69 ..CHECK -DATE: ' d e7 L�
Inform. the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM
Y
N COMMENT/CORRECTION
}}:{{^}. vi '•:C.}:\t{n+:.}:iti N� ``::;C}•�j•:' i.'n\f{U.'C •
'+ :iis`'].Ny:�y?.2..xw.`.�.;�..l,`}\,1?:►"�.\.\::I�3;4i} .i'I\ITt \1\. '\\tY..¢}.iv.!�L�C.•.:.I\\4kC }5\\V.Y.�.x.x'}J^'a�.:iv^.Y:...\\\`.;.{v\ \.\:$22.y:•�.M;;.`•,.va'n',`v�i;.}`4i•\�{}�\,\:C::i}::{+.'ti••C}.•.\\`:ti'w1:Y4{'i..•n5;?l}xt4${,.2"\WY :;•c�}2\ }C4{:v{tiC,iv:�:.t:2t`�\;\\5}`,'••'n::Wt: pv4•..x`{.}2 �\.:k,+\:.}L:1�0.v.:3;•:1K:: L••1i.{:+ri}\::{.yr'`k.•X2}�::•::vi •}`:i:k:�\vii:{•:.}in.`i{••k::}:��\.tV'.wG%}^.Y{}{��:.1\.'`v�\•:}:ga{`:'•iw{.}`::••\`p:•i .\,`\fie:�?\R
:i\}�.^•�\`+n
..,\.. \.n..,...: }::..::.:•.:.....`vn
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file las applicable)
M� 4
MDG filing required (5+ filings since 9/3/98)
BY
Consi3tency with-street/surrounding area:.
XFi(�1t
• Colors
Materials
Architecture
°
OTHER REQUIREMENTS:
The zoning code, architectural and landscaping manuals, and/or assigned inspector should
be consulted where 'uncertainties arise. The completed checklist shall be maintained in the
Building '& Safety address file.
BOB HOFFMAN , Structural Engineer
8 Sept 99
Residence at 53-060 Ave Diaz, La Quinta
for Mike Mitchell
Re : Truss design
Per Section 106.3.4.1 of the 1998 CBC, this engineer shall be responsible for reviewing
and coordinating the submitted documents of prefabricated roof trusses, as prepared by
the truss manufacturer, for compatibility with the design of the building.
�O QROFESS/pN9l
L F' 1/O F
10 m
�No 1145_ Z
OF CA1F
Sig Alfaro Drive, Rancho Mirage 92270-4758
Tel / Fag (760) 568-2967 ( Note the change)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL 1',12
Received
Address: I -,.d 12 If...
7 _Y. - �`- -
Account No
) Lot(s)
Service Address
N.Meter(s)
(X. Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
�+
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name_
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - - Bc
Assmt.
❑ Customer Deposit
❑ Other
TIT"
74870
:24,�/OF
TOTAL $ ��S•y
Remarks:
❑Copy to: /
!Cash Water Serviceeck � Z.;Coney S ti. Cashiet ,der 7 CVWD-a38 (11189)
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: 53-060 AVENIDA'DIAZ
Use Classification: SFD Bldg. Permit No.: 9905-203
Occupancy Group: R 3 Type.of Construction: VN Land Use Zone: RC
Owner of Building: MIKE MITCHELL Address:
By: .STEVE TRAXEL
f Date: 10-17-00
Building Official
POST IN A CONSPICUOUS PLACE