0304-192 (SFD)LICENSED CONTRACTOR DECLARATION `
J 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
N �a`�J� •i • j k.5 i:36 1341214.1 w 1.:aL`!(}•;.
Date °� Signature of Contractor-
s --f
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury:thaYl 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).
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 ;°J.V if> i ad3R) Policy No. 1S' W's
(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 prow sions.
r/Date: ! f Applicant
Warning Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of -this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if.
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that 1 -have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Dater
PERMIT #
BUILDING PERMIT
DATE -J° �* *` (tiVcALUATION � I i.$ �i .LOT E TRACT
MY 4,
JOB SITE ADDRESS :.`XVI i� Itx,V: AMN'A Wir.%a�
APN 774-0.9-1-008
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
3,Aa4oill IrEEL ,,E1:. p
JAN : IS C. BEITINA ; ;�R,
PALM`�'.)4,F3,4�,ger s "`s1 � 92,26.
PAT�i DA,IM s T CA. 92-1
USE OF PERMIT
MIG �+:.+V A°�`rfi.?l : fid WEL 114G,
PggyykaaI[[S]]i.t.'+aL�}[)13v, -
)V.t J_9.�}Gy`i 1� �•�
�$.i�fLr WW�`A FL' t�S. �9[7t'JJsy�b A�f?�144Sp i/l�iJ'r�. A liFt k1�. 7�•Jl� ACI4�Lerty.ML?
r'T x� Sys ay :"1114 Z Ti !P}p r
r
''PACT CONNSTRUCTION up.
:�rialiClif3',a4•d'3+�� r;i't+.�u �t�
0_,A41RA0'VCAR.PQrRT 446,0 SF
ESMIATE D'(MYT F
CONS',1'i tITTI ON YT11T, i 01-0004.1 .9.00O
U C11A11C,V.r $50& 101 _000 05-50
F ,
V.;EOTR1CAL VEVt "1 -OMP-110-000 10.000 ' 113.56
11124. LD
j
DEVILOPIN 1W.0 T 3/f' Si
q p
Fk:1i 1b�T I%1.fl.r7d �1if10C+.+�5b-4.5
E{
taJ:l`i•..�J�:?.r'l .�•�S'��`a {Z.+..'LJ.�L2 ?U.V 1J &":1.w8,�0`�.�.v.. ,
..�?r FR r��.:
Aj
JUL'O 9'-2003
CITY OF- LL.
CEIPT i lQn «_�P.
D T•E .- ' �
�,,. (orf. t
BY,./ �„�" .DAT
„F' -
FINALWNx
/
INSPE
('
."�.•
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksK1_
Q
Underground Ducts
Forms & Footings
Ducts
Slab Grade
O
Return Air
Steel
Combustion Air
Roof Deck
ti
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
InsulationVents
4a 4
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
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
r
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
- Or
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 O
Final
Utility Notice (Perm)
:,,: . �,..grad•'-'%ii5gt.at`P'`� , y :+`r • r"JIf • - i�r '�' v
P.O. BOX 1504 APPLICATION ONLY
Buildin78-495 CALLE TAMPICO
Address 5J- V_C LL, LA OUINTA, CALIFORNIA 92253
Owner
Mailing \J 1J
Address
Cityf Zip Tel.
r, 1t1 �'• G�C.�t
State Lic. I City
& Classif. �� Lic. #-C
Arch., Engr.,
Designer
Address Tel.
City Zip State gy}pp.�,;-
tL t 1 Lic. #�„i
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
' 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 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 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 fmprovement 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 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-] 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. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars ($100) valuation
or less.)
1 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 it 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 '
- - 'I,- - . >. I
LDING: TYPE'CONST.^�'.`. i OCC. GRP.
. Number fT % — (274- ,� r -}} l t
al Description rr'� : f / ��s/-I (.�'1 1 -+' "� I
ject Description
Sq. Ft. / a(
Size lJ
Add O
PERMIT .
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Gradina
Driveway Enc.
Infrastructure
TOTAL
REMARKS
All, t
No. No. Dw. /
�
Stories Units -'C,.
Alter I- Repair ❑ Demolition O
AMOUNT
sd
ZONE: BY:
Minimum Setback Distances:
Front Setbact from Center Line
Rear Setback from Rear Prop. Line
Side Street SBtback from Center Line
Side Setbackirom Property Line
FINAL DATE INSPECTOR
Issued by: Da P
Validated by:
Validation:_
-WHITE = FINANCE ' YELLOW = APPLICANT PINK =
OF LA QUIN 10% '
�inDT
CERTIFICATE OF COMPLIANCE � FIEOSC'
Desert Sands Unified School District
47950 Dune Palms Road
Q
/� `,� q BERMUDA DUNES r
Tate 7/9/03. La Qumta, CA 92253 rn RANCHO MIRAGE d
760 771-8515 INDIAN WELLS
DESERT
�.
No. 24680- -(760) d PALM DESERT
�^ LA QUINTA
+ INDIO
YYY 0 .Y
Owner James Belknap APN # 774-094-008
Address P O Box 297 Jurisdiction La Quinta
City Palm Desert Zip 92261 ; . Permit # 0304-192
Tract # BLK214 Study Area
Type Single Family Residence No. of Units 1 •
Lot # No., Street S.F. Lot # No. Street S.F.
Unit 1 • 17 53380: Avenida Villa 1604 Unit 6
Unit 2 s
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 paios/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 protect may now be issued.
Fees Paid By CC/LaJolla Bank - James Belknap Check No. 306718
Name on the check Telephone 76C,/777.9572
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempt Shar MCGi ey Payment Recd
$3,432.56 ever/Under
Signature
NOTICE: Pursuant to Government 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 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 CSpy - Accounting
' F..,. -18' 03(TUE) 10;33
FIDELITY NAT TITLE
RECORDING REQUESTED BY;
;delity National Title Company
Escraw.No_ 45937 -CS
Title Order No.
When Recorded Mail Document
and Tax Statement To:
Mr. & Mrs. J.C. Salknap
32 Camino Arroyo Place
Palm Desert, CA 92260
TEL: 1-160-779-0394
P. 002
-14-094--:00 -7 -
53-370
ASE, VALLq
7 74-094 -o0g
4VC-' V►LLq.
7 7 V -009
53" 3q
AVE. VILLIN.
7 7q d (04 - 0 1
53 - Z ZU
Rur , V LL,4
UKANT DEED- Uf4t PUR RECORDER'S USE
The undersigned grantorls) declares)
Documentary transfer tax is $198.00
1 X ] Computed on full value of property conveyed, or
[ ) computed on full value less value of liens or encumbrances remaining at tme of sale,
( ] Unincorporated Area Cltx of La Quinta
FOR A VALUABLE CONSIDERATION, receipt of which Is hereby- acknowledged, Frank Myrl Griswold, Succcessor
Trustee of The Henry Griswold .Living Trust 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 Ouinta
County of Riverside, State of Californi ;
SEE EXHIBIT ONE ATTACHED HERETOIAND MADE A PART HEREOF
DATED: January 15, 2003
STATE OF CALIFORNIA
COUNTY OF (yrs `-
ON
Frank Myrl Griswoh: , Succcessor Trustee of The
Henry Griswold Livinq Trust date Jho19, 1 95
before red
y appeared Ely:
Frank Myrl Griswol.i, rustee
Personally known to me (or proved to me on the basis
of satisfactory evidence) to be the persI nX whose
name( is/atp subscribed to the within instrument and
acknowledged to me that he/sM/the' c xecuted the
same in his/liar/thVr authorized capacityli ), and that
by his/h�/thhjr signature( on the- ins rument the
person(, or the entity upon behalf of which the
personx acted; executed the instrument.
Witness my hand and official seal
Signature 1fL I'1�s
F0•213 (Rev 7/96)
,i�
•Iii
..
�• � �1:.
MAIL TL STATEMENTS AS DIRECTED A3
i OVE.
,j(TUE) 10:34 FIDELITY NAT TITLE TEL:I-760-119-0394 P. 003 .
Escrow No. 45937 -CB
Title Order No.
EXHIBIT ONE
Lots 16, 17, 18, Block 214 of'Santa C rmelita at Vale Le Quinta, Unit 20, as per map recorded in Book 19, Page 38
of Maps in the Office of the County R corder of said County.
Lot 14, Block 205 of Santa Carmelita It Vale La Quinta, Unit 20, as per map recorded in Book
in.the Office of the County Recorder o said County. 19, Page 38 of Maps
I
�s CPI
r0�
A
Field Tech. Super. or Agent
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to. be of service.
<.
Sladden Engineering
. .6782 Stanton Ave., Suite A, Buena Park, CA 90621
(714) 523-09527. Fax (714) 5234369
39-725 Garand Ln., Suite G, Palm: Desert, CA 92211
(760) 772-3893 Fax (760) 772-3895
Cate
Job No.
FIELD
'MEMO
Project Name ou aeI?c«f C-
Client:
Site Address -3_�O 53'39a A v.c UJc. c-4
1
l
Job Phone
'. Work Done
mss+ cee- 6 fK,�,s�
Test Summary /Footings Inspected
Test
Location
Elev.
= Dry
Moist
%`Relative
:Ref. Max
:.Moist
No.
1—
U
,Density -
%
Compaction
pcf
• 2
F
�� -� • r- �
ins. ;r
� .�
g`
�
,.a , ,
N.
g -
I
tt
17
Comments
t
Field Tech. Super. or Agent
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to. be of service.
<.
Certificate of,: Occupa.ncy-
WWI
VATM
G
OF Building Y p & 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:
BUILDING ADDRESS: 53-380 AVENIDA VILLA
Use classification: SFD Building Permit No.: 0304-192
Occupancy Group: R3
Owner of Building -w JAMES C $fLKNAP. JRAddress. P.O. BOX 297
City, ST,rZIP__PALM DESERT CA 92261,
By: KIRK KIRKLAND
Date: 12-19-03
Building Official .�
POST IN A CONSPICUOUS PLACE