9803-055 (SFD)LICENSED CONTRACTOR DECLARATION
U) : I?fiereby affirm under penalty of perjury that I am licensed under provisions of
H V- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W _Professionals Code, and my License is in fulllforce a d effect.
O =) M License # Lic. Class Exp. Date
Cy LO
LU
SM r ;lam...
o Z r,- /Date —� Signature of Contractor
(DO11�
J U (p OWNER -BUILDER DECLARATIQN
WWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
C`') () I am exempt under Section B&P.C. for this reason
LID
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of,the following declarations:
LID O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W tl compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U (�(� I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
C Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
co Z)
r` MATE FUND 12 9990
J
(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 in1laRy manner so as,to become subject to the
workers' compensation laws of California, a d agree that if I should 'become
subject to the wor ers' compensation visi ns'of --ection 3700 of the Labor
Code, 19h_J f nth atF comply wi h thos �kovi io ,�".L, S
v/Date: ��L� fttApplinn nt '
Warning: Failure to secure Workers' Compention coverage is unlawful and
shall subject an employer to criminal penalties a td civil fines up to $100,000, in
addition to tha 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 reaq this application and state that the above information is
' correct. I agree to comply with allXity, and State laws relating to the building
construction, and hereby a thorize'representatives df'this City to enter pon
the above-mentioned prsope or ins�eetion purposes '\
Signature (Owner/Agent)' C"�^~-�.....+�DateJ
BUILDING PERMIT PERMIT# CONTROLL#/�
J /�
DATE - VALUATION LOT 9$03-0-5 TRACT 8 6 2 9 ",
5l $89,532.00 1 13111:. 256
JO@ SITE
ADDRESS
APN
54-015 AVE IDA UtAZ
774-194-013
'OWNER
CONTRACTOR/DESIGNER/ENGINEER
DAVID ROSS MILLER
PACIFIC TRADES CONSTRUCTION
571.9 STRENIONT
1719 S'I'REMONT
S OC:E.ANSIDE CA 92054
S OCEANSIDE CA 92054
?60}�?n i-0009 C.BL# 1955
USE OF PERMIT
14 1)
SFD - P.Ei2RlbiIT DOES NOT NCLWE BLOCK WALLS OR POOL
TRACT C`•O"NSTRUCI'iON c___1,432.W;8
GARAGEtCARPORT 514.010 SF
F'FT, WOOD FENCE 200,00 LF
111 VT[INIA fEDa: COST Cbt+' WN a'1'R5JC°1':tON
PERMIT. EEE SI)1 SIARY
CONSTKUCT:I ON FBE 101.-000-41$-000 $59.1.50
1'LE4. C1{i'CA FEE 101-000-439-318 $503.5`1
1 i4MICHANICA.LFEE 101-000-421.-000 $53.80
J }.:I.,1~.:;TRICAL FIM, 10.1-000-1120-000 $1.32.90
P1,U,L113ING FM3 101-000-419.000 �.Ir7s0
STRONG MOT10NT' - RES[D 10.1=000-242-000 58.95
GRADING FIM 10.1-000-423-000 V20.00
INFRA:SIRUCT1Jtif3.HEC7 225-000-1143-3412 $1,976.22
PRECfS3 PLAN 101-000-44.1-345 625.00
FEE DFA'031T 101-000-439-318 �23D.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$3,442.11
.LESS PRF -PAID FEES
4,11M.Lu)
TOTAL PERMIT FEES DUE NOW
$3,192.13
01
RECEIPT
DATE
BY i
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPR VALS
MECHANICAL APPROVALS
Set Backs
% _'�—_
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck
�d
Exhaust Fans
O.K. to Wrap
5/ _
F.A.U.
Framing �_�_
_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S�G9�
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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 P ^
O.K. for Finish Plaster
S r Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
/�l�/6T/J7A�f/
"Cow-x4oeaw
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
t
'Final
Utility Notice (Perm)
p
Building
40 v.v
Address t "1 c,
City
Tity/ 4 4 "
P.O. BOX 1504
LA QUINTACCALIFORNIA 92253
T.t '� ,-w ,, c -
Zip --ev
Contractor f t v, -1
�t (�%t(, t,(y\y,`-C',
Address
City lZip
'?50 ,3 - 45_6_
APPLICATION ONLY
BUILDING: TYPE'CONST. t • �)tt',� OCC. GRP.
A.P. Number
("'.. Legal Description
Project Description
State Lic. City �-
& Classif. %"M? V,_�k , Lic. # g S
Designer
Address Tel.
CityI Zip I State
I'--Lic. #
N,� rLICENSED CONTRACTOR'S DECLARATION
I hereN"affirm that I am licensed under provisions of Chapterr9 (commencing with Section
7000) of DivI to, A of the Business and Professions Code, and rAX license is in full force and
effe�t. V
OWNER -BUILDER DECLARATION
I hereby affirm hat 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 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 ($500).
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 .'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 contractors) 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. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be comp�eled if the .permit is for one hundred dollars (E 100) valuation
or less.)
I certify that in the performar`e of thffworktfor which this permit,is issued, I•shall not
employ any person in any manher s as to become subject to the Workers' Compensation
Laws of California. '1L
Date Owner c
NOTICE TO APPLICANT: If, after making this Certiricate of Exemption you fliMir3 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 1 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
Sq. Ft., `'
1
Size
New ❑
No. No. Dw.
Stories Units
Add O Alter O Repair ❑ Demolition O
Lstlmatea Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
I 11L
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
Desert Sands Unified School District
Notice: 82-879 Highway 111
01
922
Document Cannot Be Duplicated Indio, C619 -77A A 922
CERTIFICATE OF COMPLIANCE
Date 4/3/98
No. 16844
Owner NameDavid Ross Miller
APN # 774-194-013
Jurisdiction La Quinta
Permit #
No. 54-015 Street Avenida Diaz Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 1432
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:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
1.93 X 1,432 or $ 2,763.76 the property listed above and that building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now bei iessued.. ,
Fees Paid By Cashier Check/David Ross Miller Telephone
Name on the check
By Dr. Doris Wilson
Superintendent `t
Fee collected /exempted by Juanita Green Payment Received $2,763:76 \ `�
Check No. 053807
Signature
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 9"ay approval period in which you may protest the fees or other payment identified
above will begin to run from fhe 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 Dislrict('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
MAR.10.1998 3:22PM COMMONWEALTH
RECORDING REQUESTED BY:
OLD REPUBLIC TITLE COMPACOMPANY,
98.7N298KC 106898-13
wHONLMONARMEIW�FoW, °.
DAVID ROSS MILLER
1719 S. TREMONT
S. OCEANSIDE, CA 92054 '
SPACE ABOVE
GRANT DEED
NO. 556 P.1/1
S LINE FOR RECORDER'
54-0i5 AVC D:09v
The undersigned grantor(p) declare(s):
Documentary transfer tax is $18.15
(XXX) Computed on full value of property conveyed, or
( ) Computed on full value leas liens and encumbrances remaining at time of sale.
( ) unincorporated area: ( ) City of , and
FOR A VALU"LE CONSIDERATION, receipt of which is hereby acknowledged,
WILLIAM R. RILEY, TRUSTEE OP THE WILLIAM R. RILEY TRUST (1990)
hereby GRANT(S) to
DAVID ROSS MILLER, A MARRIED MAN AS HIS SOLS AND SEPARATE PROPERTY
the real property in the, City of LA QUINTA, County of Riverside, State of California,
described as:
LOT 1, BLOCK 256, UNIT. NO. 24, SANTA CARMELITA AT VALE LA QUINTA, AS
PER MAP RECORDED IN BOOK 19, PAGE 44 OF DAPS, RECORDS OF RIVERSIDE
COM=, CALIFORNIA f
Dated March 3, 1998
State or California ,
County of. } S.S.
on— _
before me,
personally appeared
personally known to me '(or proved to me on
the basis of satisfactory evidence) to be
the person(s) whose naine(s) is/axe subscribed
to the within instrument and acknowledged to
me that he/she/they executed the same in
his/her/their authorized capaeity(iep), and
that by his/her/their aignature(s) on the
instrument the person(s), or the entity upon
behalf of which the persons) acted, executed
the instrument.
WITNESS my hand and official seal,
Signature
MAIL TAX STATEMENTS TO:
LI+ R. RILEY, USTFE
'OF THE WILLIAM R. RILEY Tf:UST (1990) — -
(This area for official notarial seal)
U