0304-194 (SFD)r
LICENSED'CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
ChapteP 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 p� p
Exp. Date rr
w.
jDate Signature of Contractor 'f
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that.l am exempt from the Contractor's
License Law for the following reason:
I, ( )' 1, as owner. of the property, or my employees with wages as their sole
compensation, wll 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). 1
O 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:
O 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 issued. My workers' compensation insurance carrier & policy 'no. are:
Carrier STATE FUND Policy No. I1766%,`�
(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: 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
-6for' 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.
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ")e. (V/ Date Z
'PERMIT Jt'
PERMIT. ."
...BUILDING 0304A94
DATE7,, ^, ('VALUATION {J\ �j t �y LOT 4 TRACT 14:1,K %e
JOB E mos
ADDRESS
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
3. 109fris 13 I�^:l,F�'.?:tis
XAM0 C.1BR"�.f,04A) R, R,
AWI.:i4+S l' YIKI '�t' r CPk .- 922,611 `
T"iAts.,v9,11;k+;'� ]l :r Chi. 92261
u(?j -,,,905
USE OF PERMIT"
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". '
r�AAIIA RPORT 446.00 'ST
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ya r�gv�, ,�•�.0},gAY�.G:C
g¢30.so
PLAN C:#Al,'at; 1a31ri+ ti)1.-tCtJ dt a'3f.8 iR? 11.139
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PRE.52 i"44,44_ ... 101 -000-44,1 -345
JUL 0 9 Z J .. �,�c�Y ".V"Ya rttswav" Naw"
Z,_ A,9ea .
CIT OF LA,QUINTA ...
FINANCE DEPT.
RECEIPT
I DATE i "a \ r BYE;
DA INALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs Off
nderground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck 161—
Exhaust Fans
O.K to Wrap
F.A.U.
Framing a4 i
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final - r
BLOCKWALL APPROVALS
POOLS - SPAS
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 a
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 p
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) Jz 0
COMMENTS:
Building 5 7 - 1 �
Address -� -1
�A.b , r -..,- .,et�,.ws�•g; �r ��`r,s�i ft � �ci-�p ����rryy��.��'K��'�i�"
T4tyl.
"
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
maning tJ ,�, n t
Address C I 1
City Zip Tel.
State Lic. I City
& Classif.� Lic. #
Arch., Engr., �, 1
Designer
Address Tel
City Zip tf" State
Lic. #7�'C�
' 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
Ihereby affirm that 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 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 live hundred dollars ($500).
l' 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 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 l 1, 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 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
17 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
Ihereby 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 applicant Date
Mailing Address
Cily, State, Zip
BUILDING: TYPE -CONST. moi} OCC. GRP.
A.P. Number 77q—' r`(l`-4_ e--}�C +'
1 f
Legal Description � -� \ � 1 �4. �*+ Y' 6+� PC -5
Project Description C
Sq. Ft. No. No. Dw. Tom,
Size �. Stories Units -"
New)O/ Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT I I AMOUNT
Plan Chk. Dep. v
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front SetbacF from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback frnit Pr3p rtv Lirie
FINAL DATE
Issued by` DaEll
Validated by:
Validation: CITY OF
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
CERTIFICATE OF COMPLIANCE
Desert Sands Unified School District
47950 Dune Palms Road
a,� q Q BERMUDA DUNES O .
Date 7/9/03 La QUinta CA 92253 rn RANCHO MIRAGE �
7 INDIAN WELLS �.
760 771-8515 PALM DESERT y
No. 24681 ) ,� LA QUINTA
�INDIO
O ,
Owner James Belknap APN # 774-064-010
Address P O Box 297, Jurisdiction La Quinta
City Palm Desert Zip 92261 Permit # 0304-194
Tract # BLIC205 Study Area
Type Single Family Residence No. of Units. 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1. 14 53$20 Avenida Villa 1604 Unit 6
Unit 2 22a Unit 7
Unit 3 Unit 8
.Unit 4 Unit 9
Unit 5 Unit 10
Comments Certs #24679 through'24682 used for CC#306718 in the amount of $13,730.24. ,
z At the present time, the Desert•Sands Unified School District does not collect fees on garages/carports, covered patos/walkways, residential additions under,
500 square feet, detached accessory structures (spaces that do not contain facilities for' living, sleeping, cooking, eating or sanitation) or replacement mobile
homes. It has been determined that 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
Education Code Section 17620 and Government Code 65995 Et Seq..
in the amount of $2.14X 1,604 S.F. or $3,432.56 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed projBct may now be issued.
Fees Paid By CC/LaJolla Bank - James Belknap Check No. 306718:
Name on the check Telephone 7604777.9572
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempt y har GIIVrey Payment Recd 50.00 '
$3,432.56 Over/Under ,
Signature
NOTICE: Pursuant to Govemment Code Section 66020(d)(1), 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 projev�t is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the Districtrs) behalf, whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
F .,; -18' 03 (TUE) 10: 33
FIDELITY -NAT TITLE
RECORDING REQUESTED BY:
,delity National Title Company
'Escrow No. 45937 -Ce
Title Order No.
When Recorded Mail Document
and. Tax Statement To:
Mr. & Mrs. J.C. Belknap
32 Camino Arroyo Place
Palm Desert, CA 92260
TEL: 1-760-779-03..'94.'
P. 002
-74-Oq4-00- 5-3-370 ASE, l%ILLp
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7 7-q D 10'1 - D 1 v 53. 7 20 Avc- 1/1 LL,4
VHANT DEED— c : nw Llrvt FUR RECORDER'S USE
The undersigned grantor(s) declares)
Documentary transfer tax is $198.00
X J computed on full value of p operty conveyed, or
[ l computed on full value less value of liens or encumbrances remaining at tine of sale,
[ ) Unincorporated Area Cit of La Quints
FOR q VALUABLE CONSIDERATION re '
ceipt of which Is hereby acknowledged, Frank Myrl Griswold,, Succcessor
Trustee of The Henry Griswold Living frust dated June 19, 1995
hereby GRANT(S) to J.C, Belknap General Contractor, a California General Partnership, a General Partnership
the following described real property in the City of La Quints
County of Riverside, State of California:
SEE EXHIBIT ONE ATTACHED HERETO AND MADE A PART HEREOF
DATED: January 15, 2003
STATE OF CALIFORNIA.
COUNTY OF Qie
ON
�• ipersom
Frank Myrl GriswoIj: , Succcessor Trustee of The
Henry Griswold Livin,Wdate no 19, 1 95
before me, ���'
IY.ap.peared ey; 2U,See
Frank Myrl Griswol.
Personally known to me (or proved to mel on the basis
of satisfactory evidence) to be the person% whose
nameN is/sr,& subscribed to the within instrument and
acknowledged to me that he/slie/the' c xecuted the
same in his/Iter/thVr authorized capacityli ), and that
by his/h'hZ/thy signature(4 on the ins r ment the
person(, or the entity upon behalf of which the
person(' acted, executed the instrument.
Witness my hand and official seal.
Signature
MAIL T1 X STATEMENTS AS DIRECTED ABOVE
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Certific,
ate- of Occu an-cp y
OF'I'Y� Building &. Safety Department
This` Certificate is issued pursuant.to the requirements 'of Section.109 of the California Building
Code, certifying, that,. at the • time of issuance, - this structure ,-was in compliance with the
provisions of the Building Code and the ' various ordinances of the City regulating,. building
construction and/or user
VILLA
iBUILDING ADDRESS: 53-220 AVENIDA A1=VAR A1J
Use classification: SFD Building Permit No.: 0304-194,
Occupancy Group: R3 Type of Construction: VN Land Use Zone: R3
Owner'of Building: JAMES.0 BELKNAP �. Address: 73-300 FIDDLENECK LANE
r City, STI,,ZIP: PALM DESERT CA 92261
_ By: KIRK KIRKLAND
Date: 12-08-03
Building Offich - -
POST INA CONSPICUOUS PLACE