0109-195 (SFD)M
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
T3 HAZ
DateSignature of Contractor_
OWNER -BUILDER DECLARATION
08M IM
�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 Signature of Owner
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
tion 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 . Policy No.
VrATE FUND 20-0110411'904483
(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
Code, I shall forthwith comply with those provisions.
Date:,r., - I 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 ph forth on his
application. "' f
J "
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 voitl� if,
work is not commenced within 180 days from date of issuance of stie
permit, or cessation of work for 180 days will subject permit to cancellati,
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 ,inspeb tion purposes.
r f
Signature (Owner/Agent) --%"""� � `• � �� �� D"ate`" '' F% � A
BUILDING PERMIT PERMIT#
{
DATE / VALUATION LOT TRACT
i ,T
ell
JOB SITE /
ADDRESS
APN
544M AVENMA DIAZ
?74-T33-021.
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
36900 JA,CM(M M:
PAUAMSIERS C.tS 92261
'CHf1,1<2:i AL CA 92274
o 99•'1 X00L-k 1954
USE OF PERMIT
SM, "T ;R 1..s. 1, WT 9, MM -11 13OES'NOT iINC'6.t3t'.Jl 31.,OCK
Wk),L „l, E ootam or, D�itl:�YEWAY APPRC,�. CH.
TIZACT C9ONSTR11G2'UM 1.6.91,90 SF
PO C HIDA.'! O 122.69 SF
0ARAt3L?,i+"..Adl ORT 592,00 1qF
ESTMAI= C017r OF Cl'3.1N�r`` RUMO ,
103.13.'x.10
lr rI M, PRY. SU1,1i1MIRY,
C;auNS'1'i?ti(MON FFR i 01- -4.18' 000 S653150
PLON Ctal£ X- FEE 101-000-434',,1-318 $3014,31
HIS VOMIT 101-00'i1A39,.318 441 190
MPIC,HAN10AAIF?% _00"21 -000 U&SO
1051 4,Kk)e420-000 $117,73
F' .Y:Jp111fi33d43.l? 101-000-419-000 $I7A.00
,'1`R($1^it9 b0l'.0 T iON FRE • RF,911) 101 -OW -241 -ON W.33
101-M-42-3-000 $30.00
09MOPER IMPACT FEE $11007moo
PR =10R-0 PLdiTl `� 101-000-441-34 �1QO.mi
,p 'y
er'C» N1°1;,LtC'PAi.14 A,ND F�i�.A �C��G"I�
$3,549,37
tA 5.�,:+�3 PIM -PAD XT03
4250.10
NOV 0 7 2001
CITYOF LA QUI
FINANCE REPT -_• ...,_
RECEIPT
DATE,'
!,9 ,�/,,
BY
DAT F ALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE,.
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
Underground Ducts
Ducts
Slab Grade �'�
Return Air
Steel
Combustion Air
Roof Deck �jL
Exhaust Fans
_
O.K. to Wrap _ /��� _
F.A.U.
Framing �•�G—�j'/Lr, :
Compressor
_ - _ _ _ _
Insulation / 3_�/L.
Vents
_
Fireplace P.L. l
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath (�
Final - v -POOLS-SPAS
_ 1_6
Finai
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines- a
Heater Final
_
Water Piping �y�ZQ/0� ,, -
Plumbing Final
Plumbing Top Out ` l
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral �j
Pool Cover
Sewer Connection / ��Z�'l
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
'0
Utility Notice (Perm)
4 , ,or ?Ions
g 4 P.O. BOX 1504 APPLICATION ONLY
/ Buildin 78-495 CALLE TAMPICO
Address �lN� / A 7_ LA QUINTA, CALIFORNIA 92253
V%y7io/Y ' iiv aor Fri '7N1.
Mailing/ J3,-,,3 ?
Address ?&
City Zip Tel.
Wlh 7751.9 k 1 5.2 ?C 111 1 '77/-J176
)ip-ctor t14 1644, 4/_
State
Cla sif. 3 3(� / 2 I Licy# 390
&
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 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
1 hereby affirm that 1 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 the alleged exemption. Any violation of Secflon 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I: I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure isnot 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 infended or offered for sale. ii, however, the building
orimprovement 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 7 1 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 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: 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 sof this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number "717 -,?33-tj.l1
Legal Description Z�A.^J 9 SAL ?Gra . 1 7
Project Description J 1111c lr wfll lq
Sq. FtNo. No. Dw.
Size %b /� Stories Units
Add ❑ Alter ❑ Repair ❑ Demolition ❑
/ A 0,A I / tr14 t/-/ ;! > f -7 7/ /C 712
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal. ...�.-
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
e
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
, -i SPECTO i.
Issued by:
Dat
l
I {
Validated by:
1 1
AUG - 9 LOO
Validation:
WHITE = FINANCE YELLOW o APPLICANT
I;ITi Of
jlNANt t utPT
PINK = BUILDING.DIVISION-
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 per Section 9.50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house design does not duplicate the same architectural style of any
house within 200 -feet of-thie applicant,—and/or 2) if there is a need for the -applicant to file for
Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please
transmitted this information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT Mountain Cove Development
SITE ADDRESS 54-435 Avenida Diaz
APN 774 - 233 - 021 CASE NO.: 2001-530
LEGAL: LOT 9 BLOCK 262 UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY: Frac3 Rakar 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
Verify legal and APN.information
Consistent with MDG on file (as
applicable
MDG filing required (5 filings since
9/3/98)
IPPROVED
tiT
BY COM UNITY DEVELOPMENT DEPT
. HIBIT
Architectural variety within 200 feet of
the surrounding area: .
Colors
Materials
Architectural design features
Other Requirements:
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: SFD
Occupancy Group: R-3
54-435 AVENIDA DIAZ
Type of Construction
Owner of Building: MOUNTAIN COVE DEVELOPMENT
Building Official
Bldg. Permit No.
Land Use Zone
0109-195
RC
Address: P.O. BOX 3578
City: PALM DESERT, CA 92261
By: RICHARD KIRKLAND
Date: 04-24-02
POST IN A CONSPICUOUS PLACE
J..ul 28 01 111068 Jusitt Y=vszte p•4
VACANT LAND PURCHASE AGREEMENT
a L i a ti tv (A ANa jOINT ESCROW INSTRUCTIONS
ASSOCIATION
OP &i .AL't'l? * (AND RECEIPT POFi DEPOSIT) r
(C.A.R. Form V.M-11. Rtwhed 4MI )
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111::1 ♦i.'Si:i�Ll.i../Ylt
A. TN►S�ANoII!?.t?n` .p 1L _ s
B. Ywd AEAL TO BE AM{t pE !ra
C. rim IKIRC•1iA6L
Q. CLt3SE taF E6CRaW titan{ gDnA`\ td;ao))• ,f
� ri�iAHiti�G:obLltnlrt�awlotnsl,a4w�i arllnE.ngrdr+tsA�as,*�su�:�,��u�2i3ardlsawvwaociiow«{�oh�,r�ayleod.�lyrotatdaaargaby :�E
ri' �� in U1iva faith b ob t)10 daalpreneod ►08118 o0Wr11tp dapostt, dowel �!r. � ��
ta7rtthtt,�aruY.
A. Bi)YEi1. HAS GIVlh A lIEPOSIT TO THE AG6Fif SUOfylTT1NO = 0F�'cR ......... .. `. , ... t) o
re11d! ayµt_ ti Ate S/� + ''^ • {�
�• p • - ��..C.'7:L.e,b�l.Aa .....Dy f'etsattal
{ Chock. or 6 —,. WhM Mtall be hofa Umasheu until Acceptance ara then
1 dopa w:1111n 3 bualnoae days Mat ACCoWW" or L7
t n3tit EWOW MOldv, 13 Into 8toket s VUSt account, or 0
Buyer toprai;ontr Inas Illncq wID bO good when dsueSitad willi Escrow Hd or.
' 6. f#iCi"cASEf) btiEPOSat ohalt 1>r depushad vy fsuye► with tEs�9e1' FfOtdef w1tt.�n � Oays AUar Acoopfance, ... >t ..._.a._.�Y.-_ .-
t G FIRST LOAN IN THE AMOUNT 0!' ..^ ------•.-..--.....'.�._ �__� . __,..._.... ; _.... ...._._. �
NEW FI1at 011ed of TtuSI M lava► of 11 LENDER, ❑ SELLER: r
OR G ASSUMPtION of Existing first Ot%-d of Rust
! oacunloerfnv tho PrOporty, aootfrinp a noto payabtu Jue 0 owntr11y. dug t: ty,1� c3r;tl-atiitiial�r. e^ annutdty at numinwm �I
1145t6Yf 01 _ _ A f1xOd We. or _ w, bwal Ad)uPA- We tfl%, wh"n = mawi,•lltltle i4vilne Iffi t 4d roto Cap
• D.
0/4, laottatlCe QW in _. y0gr9, enlw'tt2¢ti QyOi ____-.• -� -rn—,* iSi {i (if tieOGkad) payabb M ..
!1 ;"_s:a - only invu m,wela). Buyer atmh pay teen Ne"orm not 10 excoo ..,---,••, ,
_W L-i. CAST{ Off. ill checked) No leen 10 noedod to owrtuuo the! Pt4w-w Bu• m 0:sa:1, wiiMIn 5 (w L)
Ovia Aftat Aa;cepiam. ptovlde Soler watt m lgttaimoon of sutfidtetlt IundS to close lois innsactlpn. 64ker
may tnnrtit `+
d►1G Agreamont en-writing within 5 Gaya Aft- (I) thea (O ptattfoo Vori(k'etion t oplrnl, If Buyar Wh to yrovwo vorpieatiOn or t
(11) waipt at ve:nlicalion, h Soot reasavW-ly dleapprovot: lt.
t a ADDITIONAL F1NANCWGTIERMS;
3
00
F BALAKE OF FURC14ASE FR" 04 ttr:4ldi+y wW N ublaa" IMM W4 O1W tSDS41p 0001 t0 4h dva4 tOd et N1 ........�
i EScr" water wii Jit SWa001w 11118 to hose 0=0%
ti. TOTAL PURCKME PRICE
H. LOM COM'"Y stmt tcx %W in #AW ut>1i111w (1e4WOCI baits; aw qt *d Of a$=%Ul Of Qxio p ill WO9 It 411 tofin (I (et C1 Oaya Air
AWOM Os. bl eAtMi tune Dir W ahWi JM Stant Wellen tIMM d OWda 0k010n b t7&W f}ds Aa ory ot it 364w)s nopes to eabl 4) t►,e " :+:d h-41: If
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t. t 6th salJcax::.Y:1 cteadeod► t�bailtely) enY bate Jn pRragiapea 21:. JLC, a e>sOwticro rt n>e Ag acintax ti NOT 1► o0t►tir►gtatty of 11+12 Ar(rsri
ft -.V4 kw4r.). N)0 tx fa i> a BLW door not pwd .tm 00 ProwrM Saba mW bn N1tW w lk,yolr da>otlt or eaar bgut x nee�ea.
fie Gypyetalri taloa d Fm ali tae
SWIM (F 11i 11 Ll c C*�, ls:E> d t!x iuyor ane 3ener ttuwwWt)y �utofpt of a copy of uda page.
teatui Q62w (womictkan of alig tam. a. 1iey polbon tlumnal. by plaffn'ovV Buyef,e tnttttaia t .Y i(.._.__._�.) iri.aoi
n vjS qle tar tang 0111ar meanw, tnG Idilug (j&miie of GOTn{quarl ad Pirne.Vi.
Copyriphi tjW,1t)Ql. CALIR)ANIA AS50CIATtON Or yQAVOk".140. beta t i In Vats l i%ry 5 � ►r ) n,a
we. ea:r+.ro PccCn.or^
YOUR COPY
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 11/7/01
No. 22652
Owner NameMounain Cove Development
No. 54-435
City La Quinta
Street Avenida Diaz
APN # 774-233-021
Jurisdiction La Ouinta
Zip 92253
Tract # BLK 262 Lot # 9 .:.,_Square Footage
Type of Development Single Family Residence
Comments
Permit #0109-195
Log #
Study Area
1691
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 NOTAAPPLICABLE
This certifies that school facility fees imposed pursuant to .'"!Government Code 53080 in the amount of
2.05 X 1,691 or $ 3,466.55 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 / Canyon National Bank - Larry Shields Te.xphone 760-771-1670
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Annette Barlow
Signature
Payment Received $3,466.55
Check No. 08084
IOTICE: 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 fees or other payment identified
bove 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