9901-095 (SFD)LICENSED CONTRACTOR DECLARATION
that I am licensed of
PERMIT#
BUILDING PERMIT
I hereby affirm under penalty of perjury under provisions
%4)1'-tt5
-6ha ter 9 (commencing with Section 7000 of Division 3 of the Business and
P ( g )
full force
DATE VALUATION ���' ." LOT i2 TRACT 1�NK+Z. �?
04 W
Professionals Code, and my License is in and effect.
11 ? t19
License # Lic. Class Exp. Date
JOB SITE
APN
W50
51)666 3/ 399
ADDRESS 53-300 AVE NIDA DIAZ
774-072-002
1'3
CONTRACTOR /DESIGNER /ENGINEER
0 Z r—
VDate 1) -, Signature of Contractor�A / �_ J
OWNER
4
F- 0
OWNER-BUILDER`DECLARATION
JACK CLARK GE''�I:RZAT, C ONT1.t1C`R.'C)!.
JACK CLAIM GEN1:RAL COPJ'1RAL." MR
a
CID
U r`
AVEN IDA CtVLRANZA
51-220 AVENIDA CARRANIM
W
W W
~
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
.51-2.10
LA Q01111 A CA 42253
LA c, j(.1tNTA CA 02253
a-
License Law for the following reason:
Z_ .
( ) I, .as owner of the property, or my employees with wages as their sole
11
35
(7E0)564-,1511 1;110) M5
compensation, will do the work, and the structure is not intended or offered,for
USE OF PERMIT
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
ti.INU1,1; 3°lA1L� 1J1L�.11oll.r
contractors to construct the project (Sec. 7044,. Business & Professionals
c'')
Code).
() I am a emp under. Section B&P.C. for this reason �•
SFO - I�EN�i7`l.[7 063 NOT INCLi,M rat.=. WALLS OR [��DOL. PLAN
LID
N
a t
Date , n F. Signature of Owner �, f %%f Ir _
CHEC�k.!'itNt'il10N OF 1-4lhS RFDUt� Ej) 71%1'Oft. NUi.'1.1PLH ISSUAiNC;lE Or
t
VWORKER'S
CL Q
COMPENSATION DECLARATION
2,Z
Cc
I hereby affirm under penalty of perjury one of the following declarations:
r � .0
O 1 have and will maintain a certificate of consent to self -insure for workers'
a iir't{ "i %£3.rS3TIVUIC1'ION e, 5:+3,{'0 1011-
X • W LL
compensation, as provided for by Section 3700 of the Labor Code, for the
POR U)PA 7110 142.0 8
O � Q
m
performance of the work for which this permit is issued.
ti}1ACtu(;AfrG�l�3 153,e+ia SP
Q'V
( ) .I have and will maintain workers' compensation insurance, as required by" -
05 U Q
L LO
Section 3700 of the Labor Code, for the performance of the work for which this
insurance &
H
Z
permit is issued. My workers' compensation carrier policy no. are:
'Policy
�.
Carver No.
qq }} y ( [y
1v rra.L4 1ON; OW F'ILD
` / (yam( / /�y�
^{ } ry {l CW
�FITIJlifir�D �w+J'AT/ 011f,('40NI STINIl.. IO Vr
!L*1t9/1gdif
Q
(This section need not be completed if the permit valuation is for $100.00 or less).
P'I)<.91W1 T VEV, SUMMARY
J
( ) I certify that in the performance of the work for which this permit is issued,
C(_',1TrRt<1UF10N F17F 1014M-418 -000 3601101
I shall not employ any person in any manner so as to become subject to the
N1AN C` 1r1rX V1 '11i trlt_ficlfl 4t+1 A!R YMX7
workers' compensation laws of California, and agree that if I should become
i ;fs i3Li't1a)7 11)1 ff00 `d�) 311-?;t6.t}C�
subject to the workers' compensation provisions of Section 3700 of the Labor
Njl CUANICAL FE6 1.01-000-421-006 55;3 Ott
•
Code, I shall forthwith comply with those provisions.
.
Date:- Applicant
1104-11U4)-n2(1t1(T() 128.2
Warning: Failure to secure Workers' Compensation coverage is unlawful and
4+I.flfbil flrc�i•4'F 1111-M)t?-41•!.1+(1!1 �12 ti7
shall subject an employer to criminal penalties and civil fines up to $100,000, in
!1TtLOIN1 f i &R. TrIOIN 111W - id's.1i1Fa $9.�S
addition to the cost of compensation, damages as provided for in Section 3706
Q0 A%f►uC� d Cfi 1.111• i1G-d23-10U1; S.''.V.--
of the. Labor Code, interest and attorney's fees.
livi ttf1S't"Ntt.h "N'Ultts FT 225.000-44.4--341 &1,U3n,S.N
IMPORTANT Application is hereby made to the Director of Building and Safety
PRTFF .).W PIAN . ii1l .,flflfl.d l- W� !t)p(1,tN1
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
STA1-'ftWAI, CQNS 1'10,, C'MON AND T"I .AN f'f•1F;C;�,
WK) its
$3—
& ..hold harmless the City of La Quinta, its officers, agents and employees.
.1
LESS PRE.'��,i1:► FEES
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
4 t:3''r�1. PERMIT 3+�1j+.`�?i11+; NOW
permit, or cessation of work for 180 days will subject permit to cancellation.
,!+
r.
•
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
(�
j(
construction, and hereby authorize representatives of this City to enter upon
cn
+ � \ {�
the above-mentioned property for inspection purposes.
/i
EC P
DATE
BY
DATE FINALED
INSPECTOR
Signature (Owner/Agent)"r�" r �� F `'` �� Date
t INSPECTION RECORD
` OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade l l Return Air
Steel Combustion Air
Roof Deck _ Exhaust Fans
O.K to Wrap F.A.U.
Framing(_ Compressor
i
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath 00
Drywall - Int. Lath
Final
_
Final a POOLS - SPAS
BLOCKWALL PPROVALS Steel
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 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
Appliances
Final
-
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole - 2 -
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 Nbtice (Perm) m
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 2/22/99
APN # 774-072-002
No. 18377 Jurisdiction La Quinta
owner NameJack Clark General Contractor
No. 53300 Street Avenida Diaz
City La Quinta zip 92253
Permit #
Log #
Study Area
Tract # Lot # Square Footage 1,505
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 mobilehomes.
It has been determined the above-named owner is exempt from paying school fees at this time due to the following
reason:
�r
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of t.
.y
1.93 X 1,505 or $ 2,904.65 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
F
Fees Paid By ccNalley Indep. Bank/Jack Clark Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Adriana Gauto Payment Received $2,904.65
Check No. 183137
Signature
NOTICE: Pursuant of Assembo 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
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
.
P.O. BOX 1504 APPLICATION ONLY
Building CALLE O
Address LA QUINTA, CALIFORNIA
92253
Owner �Q L� C,�.YK•
Mailing
AddressS
City Tel
Contractor
State Lic. 5 V + b 6, City
& Classif. 17
Arch., Engr.,
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. 7031.5,9usiness 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 lila 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
thealleged 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 (8500).
1-! 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, 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.)
I'] I 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
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 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.
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
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 applican
Mailing Address_
City, State, Zip_
BUILDING: TYPE'CONST. OCC. GRP..
A.P. Number -77 (L/ � 7:4
Legal Description ( 61t
Project Description
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
l
PERMIT AMOUNT
Plan Chk. Dep. 4;2so
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 LLiinnev
FINAL DATE INSPECTOR
AAl, �
Issued by: Date ��1y � PereAbmit`1
Validated by: R
Validation: r '
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
RC District - Planning Review
Farm
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: JACK CLARK
PROJECT
ADDRESS: DIAZ
APN:
LEGAL: LOT' 22 ,.BLOCK 181_, UNIT , S.C. @ V.L.Q.
BIN NO: 5B CASE NO. 99-39 CHECK DATE:
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
:�i4..:.}.:::::::: w:::::.v.•.v to}?;:?::::}:�::i>.t�}}y;•T}:iiir $:{:
f
:}i::tii'r�ir•:t}:;:;`.'ii:{:ji:i?:; �::v?;;i::v,>.tiii::::::ii'risjt;:SLCii;;i+'t2i^.vnv.••rr?.::. {:;:.+}:::: •: •::::}:• :+
vnh
• .• F^
MEW:: ::: .:::.......... :!•; :w::::: }?.: :•:::: }v::.:f. r::..:.:'.:'.v..v.....1................... n:::r}; w.v?:::;•::; ..:..: u...:.vv...::.v.v.
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file. las applicable)
MDG filing required (5+ filings since 9/3/98)
-Consistency-with-street/surrounding-area:
Colors
Materials APPROVED By COMMUNITY DEMLOPMENT
Architecture V1 JIM— 6 ATE !—
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.
OLD REPUBLIC TITLE CO.
RECORDING REQUESTED BY
AND WHEN RECORDED MAIL TO:
Jack Clark, Jr.
Suzanne Clark
54-350 Avenida Herrera
La Quinta, CA 92253
A.P.N.: 774-072-002 TRA #: Opp -Q/
4 AZ 177044
F A i a RECEIVED FOR RECORD
Doc. Transfer Tax AT 8:00AM
Rfv. Co. Recorder
MAY -5.1998
Reoarad in oftw Rxara
a Abaerde C -ft ceibmil
Reorder
Fees $-�—.
Space Above This Line for Recorder's Use Only _
Order No.: 108435-13 Escrow No.: 2-25333
GRANT DEED
THE UNDERSIGNED GRANTOR(s) DECLARE(s) THAT DOCUMENTARY TRANSFER TAX IS: COUNTY $11.00
[ X ] computed on full value of property conveyed, or
[[ ]] computed on full value less value of liens or encumbrances remaining at time of sale,
unincorporated area; [ X ] City of La Quinta , and
FOR A VALUABLE CONSIDERATION, Receipt of which is hereby acknowledged,
F. Jean Stokes, a Married Woman as her Sole and Separate Property
hereby GRANT(S) to Jack Clark Jr. and Suzanne Clark, Husband and Wife as Joint Tenants
the following described property in the City of La Quinta, County of Riverside State of California;
LJD
Lot 22, Block 184, Santa Carmelita at Vale La Quinta, Unit 18, in the City of La Quinta, County of Riverside, as per
map recorded -in -Book -19,i-Pages) 30, of Mapo ;u the -Office, or-the'County Recorder of said "County.
and 31
F. Jeanokes by Carroll G. She y, her attorney-in-fact
Document Date: Ayri17. 1998
STATE OF CALIFORNIA )SS
COUNTY OF Los • ArwAR-tt) ) ^� r I
On Q{2 r i l 10, 11148 before me, --To A n n —1. LLLh n, IJ 0 f V -r j Py b t tv
personallyappeared CLLrrOII G She..11u
personally known tome r roved to me on the basis of satisfactory evidence to be the person(5o whose name(IO&M subscribed to the within instrument
and acknowledged to me that�sht�tsy executes a same t is authorized capacity6m) and that b is e.*b=b signatures on the instrument
the person(io or the entity upon behalf of which the person(*) acted, executed the instrument.
WITNESS my hand and official steal.
Signature (/�K/ �•
This area for official notarial seal.
JO ANN T. ZAHN
Commission # 1143801 z
Z*MY
Notary Public — California
Los Angeles County
Comm. Expires Jun 27, 2001
Mail Tax Statements to: SAME AS ABOVE or Address Noted Below
1;
CITY OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS_ YC
bf f -Z LoI22,PERMIT NUMBER OWNER_ BUILDER 3stce— C.tAP. - Jr.
This form shall be posted on the job .with the Building Inspection Card at all times iri a conspicuous place. Only persons appearing on this list or their employees 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 stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Company Name
A r M coAmo cm ont
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
fxx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
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LN 30 -dig
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
53-300 AVENIDA DIAZ
Bldg. Permit No.
Type of Construction: VN Land Use Zone
Owner of Building: JACK CLARK GENERAL
CONTRACTOR
Building Official
9901-095
RC
Address: 51-220 AVENIDA CARRANZA
City: LA QUINTA, CA 92253
By: STEVE TRAXEL
Date: 10-14-99
POST IN A CONSPICUOUS PLACE