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04-4554 (SFD)Tdf 444" P.O. Box 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING PERMIT BUILDING:& SAFETY DEPARTMENT (760).777-7012 FAX (760) 777-7011 INSPECTION REQUESTS (760) 777-1153 a Application Number . . . . .. ��0-4 00004554", Date 9/17/04 Property Address . . . . . . 8-02UO----VI-A--PESSARO APN: 772 -550 -016 - Application description . . . DWELLING - SINGLE FAAILY DETACHED Property Zoning . . .. . . . . LOW DENSITY RESIDENTIAL Ap plication valuation . . . . 298827 Owner Contractor ------------------------ JEFFREY B. JACOBSEN ------- : ----------------- MONARCH HOMES, INC. 73-290 EL PASEO # 4 73290 EL PASEO, SUITE #4 PALM DESERT CA 92260 PALM DESERT CA 92260 (760) 568-3905 WCC: STATE FUND WC: 0002.290026122 06/01/05 CSLB: 809638 06/30/06 CCC: B ------ Structure Information 3485 SQ. FT. SFD Construction Type . . . . . TYPE V - NON RATED Occupancy Type . . . . . . DWELLG/LODGING/CONG <=10 Flood Zone . . . . . . . . NON -AO FLOOD ZONE Other struct info . . . . CODE EDITION 2001 CBC #2EDROOMS 3.00 FIRE SPRINKLERS NO GARAGE SQ FTG 625.00 PATIO SQ FTG 375.'00 NUMBER OF UNITS 1.00 FIRST FLOOR SQ FTG 2762.00 ------------------ SEC OND FLOOR SQ FTG 723.ob --- ---------------------------------------------------- Permit . . . . . . BUILDING PERMIT Additional-desc Permit Fee 1336.00 Plan Check ---ee 868.40 Issue Date . . . . Valuation . . . . 298827 Qty Unit Charge Per Extension BASE FEE 639.50 199.00 3.5000 ---------------------------------------------------------------------------- THOU BLDG 100,001-SOO,000 696.50 Permit . . . . . . MECHANICAL Additional desc Permit Fee . . . . 96.50 Plan Check -7ee 24.13 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension P.O. Box 1504 78-495 CALLE TAMPICO VOICE (760) 777-7012 LA QUINTA, CALIFORNIA 92253 4 4 a" FAX (760) 777-701 1 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 0 Z4 554 Date:?-/ Zz�4 Applicant: kcAect or Eggileer- 1-20 Applicant's Mailing Address� Architector En_qbeer'_Address: V� 0& po a re-cw-Tv /0 /Lic. No.: C-- -2-z- `5 1_') 7 BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S 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,&n full force and effect. ,_-<,'cense Class 17:> .,,6eense No. 90 9 6,8,? Datef,17, cP ontractol& ]4Z_C a0J4rZC_,(J- 4L AA..EirS 1p—C C_ OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violafion 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).): U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work himself or herself or through his or her own employees, provided that the 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 or she did not build or improve for the purpose of sale.). U 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. _, BA P.C. for this reason Date — Owner. WORKERS'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 Section 3700 of the Labor Code, for the performance of the work for which this permit is _.Asued. Myte*jers'compensation ipwance carrier and_policy nu ber are- -el-er 15.T&_1re ,,ocodrn -Il'olicy Number 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 pr I ions.--.,: .17-04 WARNING: FAILURE To SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lenders Name Lenders Address APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnity and hold harmless the City of La Quinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 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 igIldrmation is correct. I agree to comply with all city and county ordinances and state laws relafing to building s cou I, construction, and hereby authorize representatives of thi n y n purposes. ,- �Datea_L�Z --signature (Applicant or Agent) Page 2 Application Number . . . . . 04-00004554 Date 9/17/04 Qty Unit Charge Per Extension BASE FEE 15.00 2.00 9.0000 EA MECH FURNACE <=100K 18.00 2.00. 9.0000 EA MECH B/C <=3HP/100K BTU 18.00 5.00 6.5000 EA MECH VENT FAN 32.50 2.00 ---------------------------------------------------------------------------- 6.5000 EA MECH EXHAUST HOOD 13.00 Permit . . . . . . ELEC-NEW RESIDENTIAL Additional desc . . Permit Fee 164.48 Plan Check Fee 41.12 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 3485.00 .0350 ELEC NEW RES - 1 OR 2 FkMILY 121.98 625.00 .0200 ELEC GARAGE OR NON-RESIDENTIAL 12.50 1.00 ----------------------------- 15.0000 EA L ELEC TEMPORARY POWER POLE 15.00 Permit . . . . . ---------------------------------------------- PLUMBING Additional desc . . Permit Fee . . . . 161.25 Plan Check Fee 40.31 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 15.00 6.0000 EA PLB FIXTURE 90.00 1.00 15.0000 EA PLB BUILDING SEWER 15.00 1.00 7.5000 EA PLB WATER HEATER/VENT 7.50 1.00 3.0000 EA PLB WATER INST/ALT/REP 3.00 1.00 9.0000 EA PLB LAWN SPRINKLER SYSTEM 9.00 9.00 .7500 EA PLB GAS PIPE >=5 6.75 1.00 ---------------------------------------------------------------------------- 15.0000 EA PLB GAS METER 15.00 Permit . . . . . . GRADING PERMIT Additional desc Permit Fee . . . . 15.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension ---------------------------------------------------------------------------- BASE FEE 15.00 Special Notes and Comments 3485 SQ. FT. SFD. THIS PERMIT DOES NOT f / Fee summary ----------------- Permit Fee Total Plan Check Total Other Fee Total Grand Total Charged Paid 1773.23 Page 3 Application Number . . . . . 04-00004554 Date 9/17/04 ---------------------------------------------------------------------------- Special Notes and Comments 500.00 INCLUDE'POOL & SPA , BLOCK WALLS OR DRIVEWAY APPROACH. 9/16/04 7:24:23 AM JJOHNSON ----------------------------------------------------------------------------- Other Fees . . . . . . . . . ART IN PUBLIC PLACES -RES 247.06 DIF COMMUNITY CENTERS -RES 97.00 DIF CIVIC CENTER - RES 366.00 ENERGY REVIEW FEE 86.84 DIF FIRE PROTECTION -RES 97.00 GRADING PLAN CHECK FEE ' 00 DIF LIBRARIES - RES 225.00 DIF PARK MAINT FAC RES 5.00 DIF PARKS/REC - RES 502.00 STRONG MOTION (SMI) RES 29.88 DIF STREET MAINT FAC -RES 15.00 DIF TRANSPORTATION -- RES 1098.00 Fee summary ----------------- Permit Fee Total Plan Check Total Other Fee Total Grand Total Charged Paid 1773.23 * 00 973.96 500.00 2768.78- .00 5515.97 500.00 Credited Due .00 1773.23 .00 473.96 .00 2768.78 .00 5015.97 14JI RO. BOX 1504 Building 78-495 CALLE TAMPICO Addressle-6200 V11,4 LA QUINTA, CALIFORNIA 92253 I:F - 11-4 r EV Mailing -0-V Address Z2_ d 'V�t-Z60 Address - 30 &'z- 6�0 J01- -7:3 P5 QLV � ' & Classif.9011&-V _1h Arch., Engr Designe�� Addres& Tel. I 0/4LL;;iri I I-ip Olale 600-1vi"i'00 "/04? 1 Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (command ith Section I force and effect. 9P 7000) of Division 3 of the Business and Professions Code, and my license is 9 In EIGNATURE DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for he following reason: (Se.. 7031.5, Business and Professions Code: Any city or county wh h 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 licen d pursuant to the provisions of the Contractor's License Law, Chapter 9 (commencing with S ction 7000) of Division 3 of the Business and Professions Code, or that he is exempt therefro , and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for permitsubjects the applicant to a civil penalty of not more than five hundred dollars ($500). 0 1, as owner of the property, or my employees with wages as their sole com ensation, will do 0., B the wo rk, and the structure is not intended or offered for sale. (Sec. 7044, Bus ness and Profes v w I -to c -t at fo h r a ty li a I r0 w n0 - I Sh s r pa c a in ens Bus nes' sions, Code: The Contractor's License Law does not apply to an owner of or, perty who builds or improvEiis thereon and who does such work himself or through his own em loyees, provided that such Imp vements are not intended or offered for sale. If, however, I e building or im- provement is sold within one year of completion, the owner -builder will h ve the burden of proving that he did not build or improve for the purpose of sale). 0 1, as owner of the property, am exclusively contracting with licensed cont actors to construct the project. (Sec. 7044, Business and Professions Code: The Contractor' Li . cense Law does not apply to an owner of property who builds or improves thereon, and wh contracts for such 7 projects with a contractor(s) licensed pursuant to the Contractor's Licens Law) 0 1 am exempt under Sec. - B. & P.C. for this reason- I Date- Owner .1 WORKER'S COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure, or certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labo Code.) Policy No. - Company 0 Copy is filed with the city. 0 Certified copy is hereby furnishe CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANC (This section need not be completed if the permit is for one hundre dollars ($100) valuation or less). I certify that in the performance of the work for which this pe it is issued, I shall not employ any person in any manner so as to become subject to Worke 'Compensation Laws of California. Date- Owner NOTICE TO APPLICANT If, after making this Certificate of Exam tion you should become subject to the Workers' Compensation provisions of the Labor ode, you must forthwith comply with such provisions or this permit shall be deemed revoke CONSTRUCTION LENDING AGENCY I I hereby affirm that there is a construction lending agency for th 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 vali � ated, and is subject to expiration if work thereunder is sus pended for 180 days. I certify that I have read this application and state that the above nformation is correct. I agree to comply with all city and county ordinances and state law relating to building c s it on truction, and hereby authorize representatives of this city to enter �e above-mentioned property for inspection purposes. Signature of applicant Mailing Address City, State, Zip WHITE = BUILDING DEPARTMENT 0-f— ?erav_ - APPLICATION ONLY BUILDING: TYPE CONST.— OCC. GFIR A.R Number 7 ZZ - - 0/( g Legal Description. 6V7- -Z-OZ- Project Description 5�_ J-) Sq. F. No. Size Sto No. Dw. Newly', Add 0 Alter 0 Repair 0 Demolition 0 '100, f � -F -74,0 Z -,'7S 40 -7 C) Estimated Valuation PERMIT AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure I L TOTAL REMARKS ZONE: BY: Minimum Setback Distances: —Front Setback from Center Line Rear Setback froin Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by:— Validated by: I Validation: YELLOW = APPLICANT Date PINK = FINANCE Coachella Valley Unified School District P.O. Box 847, Thermal, CA 92274 (760) 398-5909 — Fax (760) 398-1224 This Box For District Use Only DEVELOPER FEES PAID AREA: AMOUNT LEVEL ONE AMOUNT: LEVEL TWO AMOUNT: mr[GATION AMOUNT: COMMAND. AMOUNT: nATF.- RF.r.F.IPT- r.kF.(.K 0- INITIALS - CERTIFICATE OF COMPLIANCE (California Education Code 17620) Project Name: Residence at Hideaway Date Sept mber 17, 2004 Owner's Name: Jeff Jacobsen Phone SZ? — /-/,o -7,q Project Address: 80-200 Via Pessaro La Quinta, CA roject escription: New SFD APN: 772-550-016 Tract Lot rype of Development: I Residential xxx I Commercial Industrial Total Square Feet of Building Are 13,485 sq. ft. Certification of Applicant/Owners: The person signing certifi s that the above information is correct and makes this statement under penalty of perjury and further represents that he/she is a "Od tos=' on behalf of the owncr/developer. September 17, 2004 SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE) Education Code Gov.Code Project 17620 65995 Approval Note: Number of Sq.Ft. E3,485 Amount per Sq.Ft. $2.68 $9, 9.� Amount Collected $9,339.80 Building Permit Application Completed: Yes/No By: Carey M. Carlson, Asst. Supt., Business Services Certificate issued by: I Elvira Mattson, Office Technician Agreement Existing Not Subject to Fee Prior to 1/1/87 Requirement NOTICE OF 90 DAY PERIOD FOR PROTEST OF FEES AND STATEMENT OF FEES Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this Di.-trict provide (1) a written notice to the project appellant * at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90-dhy period to protest the imposition of these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the Government code and otter applicable law, this Notice shall serve to advise you that the 90 -day protest period in regard to such Fees or the validity thereof, commences with the payment of the fees or performance of any other requirements as described in section 66020 of the Government code. Additionally, the amount of the fees im:)osed is as herein set forth, whether payable at this time or in whole or in part prior to issuance of a Certificate of Occupancy. As in the lafter, the 90 days itarts on the date hereof. This Certificate of Compliance is valid for thirty (30) days from the date of issuance. Extension will be granted only for good cause, as determined by the School FIDELITY NATIONAL TITLE COMPANY SUBDIVISION DEPART&IENT WHEN RECORDED MAIL TO: Mr. Jeffrey B. Jacobsen 2209 Arizona Avenue Santa Monica, CA 90404 Doc a a00a-10204SZ 12/30/2003 08:00A �ee:16.00 Page I of 4 Doc T Tax Paid Recorded in Official Records County of Riverside Gary L. Orso Assessor, County Clerk & Recorder 1111111111111111111111111111111111111111111111111111111 MAIL TAX STATEMENT TO: SAME AS ABOVE M S U SIZE DA misc. _�AGE I A R :�L] COPY LONG I REFUND NCHG I EXAM DOCUMENT TRANSFER TAX $ q?q - 6D XX Computed on the consideration or value of property conveyed; OR DQ3 Computed on the consideration or value less liens or encumbrances' FT t-*, remaining at the time of sale. LMA j 0-6 F�1- Signature of Declarant or Agent determining tax - Firm Name i��— - TM -Vao 0 GRANT DEED FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged, ND LA QUINTA PARTNERS, LLC, a Delaware limited liability company ("Grantor"), hereby GRANT(S) to Jeffrey B. Jacobsen, a single man ("Grantee"), the real property located in the City of La Quinta, County of Rivers: -de, State of California, described as: See Legal Description attached hereto and incorporated herein as Exhibit "A". SUBJECT TO all matters of record including, without limitation, the covenants and agreements described in Exhibit "A" attached hereto. Dated: 0 3 ND LA QUINTA PARTNERS, LLC, a Delaware limited liability company By: Nationwide Realty Investors, Ltd. an Ohio limited liability com y its:ma4nagm A?enmber p /, 11 . V-,,vp By: Jos L. �r Jos Dph L. Arenson Authorized Representative STATE OF. California COUNTY OF Riverside Ora December 26, 2003 before me, K. Larby, Notary Public (Name, Title of Officer) personally appeared Joseph L. Arenson personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. tary Public) OFFICIAL SEAL K. LARBY COMM 0 1268797 C) NotmY Public - California NVERSIDE COUNTY Nly Commission Expifes JUNE 24, 2004 (This area for notarial seal) EXHIBIT"A" Legal Description Parcel No. 1: Lot 202 (the "Lot") of Amended Tract No. 29894-2 as shown on Subdivision Map (the "Map") recorded on December 12, 2002, in Book 327, Pages 56 to 88, inclusive, of Maps, in the Office of the Riverside County Recorder. EXCEPTING AND RESERVING THEREFROM TO GRANTOR, and its successors, assigns, invitees, licensees and employees, together with the right to grant and transfer all or a portion of the same, all easements and rights for access, ingress, egress, encroachment, maintenance, drainage, support, and for other purposes over the Association Maintenance Areas and other portion of the Lot, reserved to Grantor in the following instruments: I . The Amended and Restated Declaration of Covenants, Conditions and Resffic-ti6ns"and Res*eivati6h of Easements for The Hideaway Owners Association (as amended or supplemented, the "Declaration"), recorded on December 13, 2002, as Instrument No. 2002- 745939, of Official Records of Riverside County, California (the "Official Records"); 2. The Supplementary Declaration of Annexation of Property, recorded on March 21, 2003, as Instrument No. 2003-201647, of Official Records of Riverside Country, California. FURTHER RESERVING THEREFROM, the right to enter the Lot for a term of twelve (12) months following the recordation of this Grant Deed, to complete and repair any improvements or landscaping located thereon as determined necessary by Grantor, in its sole discretion, in order to comply with requirements for the recordation of the Final Tract Map, the grading of said Tract and/or in compliance with the requirements of applicable governmental agencies. Such entry by Grantor shall be preceded by reasonable notice to Grantee before such entry. If this reservation of right of entry is not complied with by Grantee, Grantor may enforce this right of entry in a court of law. Grantee shall be responsible for all damages arising out of said breach including attorneys' fees and court costs. This reservation of right of entry shall automatically expire twelve (12) months from the recordation of this Grant Deed. FURTHER RESERVING THEREFROM, an easement for landscaping purposes over the Southerly 11.5' feet thereof. Parcel No. 2: Nonexclusive easements for access, ingress, egress, drainage, maintenance, repairs and for other purposes, all as described in the Declaration. -0 SU13JECT TO: 1. Non delinquent general, special and supplemental real property taxes and assessments. 2. All other covenants, conditions, restrictions, reservations, easements, rights and rights-of-way of record including, without imitation, the Declaration and the Map for Tract No. 29894-2. Grantee, by acceptance and recordation of this Grant Deed, hereby (a) accepts and approves all of the foregoing in this Grant Deed, (b) grants to Grantor and The Hideaway Owners Association such powers and rights as are set forth in the Declaration, and (c) accepts, covenants and agrees to be bound by and assume performance of all of the applicable provisions and requirements set forth in the Declaration, including Section 13.15 establishing the procedure for resolving disputes with Grantor, and the notice, which provisions and requirements are acknowledged to be reasonable and incorporated herein by this reference there.. --o. This grant is conditioned upon the performance of such provisions and requirements as are to be performed by Grantee under the Declaration. The restrictions on use and occupancy of the Lot are set forth in the Declaration'.to which- this Grant Deed is specifically and expressly made subject. GRANTEE HEREBY ACCEPTS AND APPROVES THE FOREGOIT4G, granting unto Grantor and The Hideaway Owners Association such powers and rights which are set forth in the Declaration defined above, on 49, go- 2003. Jeffrey f3. Jaco'bsen STATE OF COUNTY OF )ss. On 205- _2,0-3 2003, before me, the une-ersigned, a notary public in d for said State, personally appeared Jeffrey B. Jacobsen, personzlly known to me (or prov the basis of satisfactory evidence) to be the persons whose names are subscrib o , e wi in instrument and acknowledged to me that they executed the same in their authoriz d c acities and that by their signature on the instrument the persons, or the entity upon behalf o hi the ersons acted, executed the instrument. ub'lc m 'or prov subscrib au onz ehalf 0 d or s� _f id State o 0 t s me n he ba i' 0 n mstl th c and th. e rso s. n W1 S --AND OFFICbV:.,SEAL. RT(____1 ANTHOW BA )N COMM. IP1411236 [SEAL] 0 NOTARY PUBLIC - CALIFORNIA 0 0 0 Signature RIVERSIDECOUNlY MY COMM. EXPIRES APRIL 15,2007 My commission expires: 41 -K4 2VO-1