0304-193 (SFD)/ t
LICENSED CONTRACTOR DECLARATION
j,here'by 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
11
,Date Z Y," Signature of Contractor fir'-�,"
OWNER -BUILDER DECLARATION
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).
( ). 1, as owner of the property, am 'exclusively contracting with licensed
contractors to d6h9truC1 Ire project (Sec. /u44, BUSIIIeSS & PIUfeSslUI1als
Code).
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:
() 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 �ITAT/r, FUND Policy No. I.Y!6r)3
(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: �f%,F Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and.
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety.
for •a permit subject to the conditions and restrictions• set forth on his
application.
1. Each person upon whose behalf this application is made & each person a,C
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton .agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its. officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation:
I certify ,that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building,
construction, and hereby authorize representatives of this City to enter upon
the, above- mentioned property for inspection purposes.
� Signature (Owner/Agent) ? r / % 'Date'.,,) "1
:i
PERMIT #
BUILDING PERMIT��
DATE -` VALUATION Pip a@� 6�pf� .LOT, S TRACT . 111.K 714
..fit
JOB SITE
ADDRESS pS r`► x Z cEl.:YiYi�T:,i�
APN 77, x�.4
OWNER - "
CONTRACTOR/DESIGNER/EN (NEER
i 1, a, X , .
ti,
wCn,a�r v i0.u3::ii
y4�r���?g,
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(r sir 557,2 CIRd# 2905
USE OF PERMIT _
6w"X,•`-a(,�:I:.Ts'k`.�t�,:9;{T,.Y'.t''.'yP�.�i.;f �C� ,
.
lJOA+?,pSlNNP.i:�A� l�tsRT1Y..D,CifFdt idtClH. �, s1�1.5•l-.,JfCq.Fe.De,l'l..�f..as-Ad'4Wv.r, 1C,1O,M4.�, .n�Jt✓,,�
+�6.
J1VAa..rE{;P
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PLAN FOR
17I_ NS Or &A..Mi;r 7YPR?
ki 't;l2C'Ii1 .61' '4{ 13'3,4iin'. SP
440 S .
Arp.D c Cv7' f»�t , ' a?'C. Ys .AT
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F t5f 19 t'.' 10'j -000-435.31$- 4736,00
;inR, zAr Yet11. ,e11"V 101-000-421 -000 - io
�M'�.'�i PrlLa�i�1.3 t'•��13 i,Wj .U�i3°'=M Cy—i��� ���e� i✓°�
S i ACINO M.0 XYR F?tC3y - ft4'XID 'f, 0 f .foot l - 3.0flo.
On r1J711 N t"!S f:. `. 01 _00t<wt•1A1Z2;..dtOfJ'
FRECISF,P1,A'Nf t,006--,141-34
6 K. ;isbn:%i ie "Tiwitis%AND PLJW (MVCK
JUL 0'9'.2003!'
CITY OI: LP 0I,f4r.,fi
'401
RECEIPTDATE - BY , D T INALED INS
T R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
C5
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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 Test77_7
6,77
Appliances
Final
Final 44
Utility Notice (Gas)
ELECTRICAL APPROVALS y
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) p
COMMENTS:
..'YT y r -F�rwrw,M' '", r lr�r% ( l 'v+ '�+'Ii�"'�/' „rf and w.. -"+',"i„jC�xq-•• �+p.yy�.�rT '?iw'"'tf Ww
•0
��
0804f i 1 P.O. BOX 1504
Building 2,?��78-495 CALLE TAMPICO
Address '- V,..;i� LA QUINTA, CALIFORNIA 92253
Owner l
Mailing `t
Address
City Zips ! Tel.,_
li/; 1 f
s f n I
Aaaress
City. �f
State Lic.
& Classif.
Arch., Engr.,
Designer
Address
rr Zip Tel.
City
Lic. #0011
112 Ni.
Tel. f
CityZi,p �J State
Lic. #
r 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. i
SIGNATURE 1 DATE
OWNER -BUILDER DECLARATION
I hereby 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 rive hundred dollars ($500).
I: I, as owner of the property, or my employees with wages as their sole compensation, will
do the works 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 or sale.)
I -I 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
doesnot apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(a) licensed�pursuant to the Contractor's License Law.)
i ] 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. ❑.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, atter 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
City, State; Zip
qoZ 7`/`Vy
APPLICATION ONLY
BUILDING: TYPrE•CONST.��J OCC. GRP.
A.P. Number P/ 11•/ - C�4 -
r �`
Legal Description 4 tJ t_.r.! <�;`,'�1 �! t4'
Project Description .�� 7- . �0 ��I'!"� v ,-•f. _ l_ry `..
1-14J J
Sq. Ft. No. No. Dw, �••.
Size r�( Stories Units ---
Nevin] Add ❑ Alter ❑ Repair ❑ Demolition ❑
PERMIT AMOUNT_
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setbact from Center Line
Rear Setback from Rear Prop. Line
Side Street S"stback from Center Line
Side Setb�ckirom Property Line
' r
FINAL DATE INSPECTOR
Issued by: Da -e il Perfi�l1 A n
Validated by:
Validation:
CITY OF LA
WHITE = FINANCE YELLOW = APPLICANT PINK
f
CERTIFICATE OF COMPLIANCE vFsc
Desert Sands, Unified School District
47950 Dune Palms Road BERMUDA DUNES .
Date 7/9/03 La Quinta CA 92253. (A) RANCHO MIRAGE ti
INDIAN WELLS "ter
No. 24682 (760) 771-8515 PALM DESERT
LA QUINTA ,,�y
e INDIO `^
Owner James Belknap APN # 774-094-009
Address P O Box 297 Jurisdiction La duinta
City Palm Desert Zip 92261 Permit # 03C,4-191
Tract # BLK214 Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 16 .53390 Avenida Villa, 1604 Unit 6
Unit 2 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.
At the present time; the Desert Sands Unified School District does not collect fees on garages/carports, covered palos/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 $2.14 X 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 prof-=ct may now be issued.
Fees Paid By CC/LaJolla Bank - James Belknap Check No. '306718
Name on the check Telephone 7601777.9572
Funding Residmtiial
By Dr. Doris Wilson
Superintendent
Fee -collected /exempted by Sharo cGilvrey . Payment Recd 50.00
' $3,432.56 mer/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90 -day approval perod 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 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 District('s) behalf,*whichever is earlier.
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
-'-V _ _Y`3 `/P'.='Y •` �'^i�-Mi1-`.. -
�j'�...♦ "YLai���kr �+�/, `J j, x
Elev.
Dry
Moist
% Relative
Ref. Max
Moist
No.
Sladden
Engineering
6782 Stanton Ave., Suite A, Buena Park, CA 90621
39-725 Garand Ln:, Suite G, Palm Desert, CA 92211
pcf
%
A.
1
(714) 523-0952 Fax (714) 523-1369
(760) 772-3893 Fax (760) 772-3895 -
FIELD MEMO
Cate
Job No.
Project Name-cx.d Client: r
Site Address =,3 37D Aoe UL-L--tet
-z
Job Phone
W6rk'Done °
' .-....-•-.,.� . . � � ` }�..- � C/`Yy .1c�-G....L�-G^`` if'Y, / raj- � C ,?'�l �(%/C'�'- . ' � e
.2a
Test Summary /.Footings Inspected "=3
'Test
Location
Elev.
Dry
Moist
% Relative
Ref. Max
Moist
No.
Density
%
Compaction
pcf
%
Comments
I
4 Field Tech.. Super. or Agent
24 hour notice requested -to schedule field Technician. Thank:Vou,for the opportunity to be of service.,
n
*Sladd'e'n Enginleering ,
6782 Stanton Ave., Suite A, Buena Park, CA 90621 (714) 523-0952 Fax (714) 523-1369
39-725 Garand Ln., Suite G, Palm Desert, CA 92211 (760) 772-3893 Fax (760) 772-3895
Date
Job No.
FIELD MEMO.
Project Name 6U -no ?c d � Client:
Site Address -3 53'350 A
Job Phone
Work Don'e'
Ely
S
Test Summary / Footings Inspected
Comments
r
J
Field Tech. Super. or Agent
f 24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.,
Certificate of Occupancy
Td
At -4,
-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 use. I
BUILDING ADDRESS: 53-370 AVENIDA VILLA
Use classification': SFD
Occupancy Group: R3
Owner of Building: JAMES C BELKNAP. JR
Building Permit No.: 0304-193
Address: P.O. BOX 297
City, ST, ZIP: PALM DESERT CA 92261
By: KIRK KIRKLAND
Date: 12-19-03.
IN A CONSPICUOUS PLACE