9607-124 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
:C'rhap' & 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
62_5320 13 8/311k)7
mate '1- ?Signature of Contractor _
OWNER -BUILDER DECLARATION
r
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 oropertv, am exclusively contractina 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
Sec ion 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 CPolicy No.
A 1ND6"N%TY N5041I34A
(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
bject to the workers' compensation provisions of S ction 3700 of the Labor
Code, I shall forthwith comply with those,p""roril'sI A
Date: 1 r Applicanty�/��dL^
Warning: Failure to secure Workers' Lmp,,�ers_ation coverage is unlawful and
shall subject an employer to criminal penalfies 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, indemnity
& 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 inspectiofi purposes. r
Signature (Owner/Agent) VDate
BUILDING PERMIT PERMIT# CONTROL#
96,07-124
4634DATE.
VALUATION St{Cl,if7'3.2�1 LOT TRACT
JOB SITE
ADDRESS rJ L2 AVENJDA. VILLA
APN 773-274-009
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SC CTI, c" 01,11.00*:
li1S CONS'1`Rt.1C'1` ON
NPI POUR Pt4PHS IN
52433.AVtN1,43A VILT A
1§i40VI DA DUNES CIN 9.201
TA 4 UIN'TA. CA 92253
(614)77.1-/1510 03L# 1944
USE OF PERMIT
y
iter)_ PHItMi't 00j:lfii NOT NC1..fJii: E BLO K WALL 012.POOL.
1PMA�t�"+B. CON,`-,"IR1L;0i :10lilt 4, 1180.00 Z
�;rlt"tAC:flb"t �C;Ct'.i 427.00 SIP
Cf2S ' Cr3' t-01` '1:1 �lG:'� f(-XN
105,023.20
PERT77�� `` { ((pp� ti YYt!y','D
.�rll�.11UT-'.IEC' S(Jl1'aMAIty
CCINSTRI FEUR 101 -000-418-OM $660 5"
j�►,�rt �°°'+►�r�l` ! i;j: t�y_t1C!l1-43�-llf� �4�4.
PU04 C'IIECR DEPOSIT 4250,00
c�l1..e.;.I'IrtNEC:r�I. (<f.i:;1 Mil-{�N)G-4521.-Gflii StU.ijlj
I.i!;=:fRfCWL FVRS $134.M
I It I V01 NO
,319 +a14t.i hf.{,3`t �t iv (1Lf yb Z413 in`dtl.. .:11_ Vllt1 $10-50
Ok /i f)f W) S20.00
fNPT(x1',' 1.4 11.110.' 225-000-443-34e
1404118!, P4. a,N 1,():-000-x#411»3,15 ` ?S.0()
/Aft•' 114 PUBLIC,11LA.f:`.i,8. (1?03� 705-000.255-000
481i�€�C."+IONA f,) PIAN x'1.1fs�;�
fi3���a3
b! SS PR1-PAID 83,68
-$250.0{)
PAID
','OTA ., PaNNI t IF'Ek'S DUE NO%`
JAN 22 1997
T
`EGEIDT I t i
BY;DATE
FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
0Exhaust
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 Wall Firewall
Exterior Lath
oq
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 Pibg. Test
Final
I I
Gas Piping
PLUMBING APPRO ALS
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
D
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRIC -111'A PROVALS
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)
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201 r
619 -775 -3500 -
CERTIFICATE OF COMPLIANCE
Date 1/8/97 APN # 773-274-009
No. 15168 Jurisdiction` La Quinti
Owner Name Scott Gordon 'Permit #
No. 52412 Street Avenida Villa Log #
City La Quinta Zip 92253 Study Area 122
Tract # Lot # Square Footage 1780
Type.of Development Single Family Residence t No. of Units 1
Comments
At the present time, the Desert Sands Unified School District does notcollect 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 tine due to the following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 i_ -i the amount.of
1.84 X 1,780 or $ 3,275.20 , the property listed above andtthat building
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
4 y' ;P
Fees Paid'By cc/First Bank/Scott Gordon Telephone{ 771-4540
Name on the check
By Dr. Carol McGrew R
r C,
Administrator in Charge
Fee collected /exempted by Pauline Pearson Payment Received $3,275.20
.Check No. 36723
Signature t!
NOTICE: 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 prcest 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 sssued or on which they are paid to the District(s) or o another public entity authorized to
collect them on the Dislrict('s)(s') behalf, whichever is earlier.
ri
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
••,•nL fllLt:1N5URANCE`CQ:`
-It XORDING REQUESTED BY:.
FIDELITY NATIONAL TITLE COMPANY
96.5799DT 271-712
WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TO:
SCOTT GORDON '...r
79371 FOUR PATHS LANE4
BERMUDA DUNES, CA 92201
r Yt 225664. '
RECEIVED FOR.RECORD
AT.8:00 a6WcK' `.. .
,_--;,:•�-
l`9'1996
pI 'D . Ro=W inOffkW R000N.
.t RlgniOeCounty.Cftria
Doc. Transfer.Tax
F. RANK K. Recorder �r
JOHNSON Recorder
Aiv. Co. F.'ss `
e
a IS LINE FOR\
RECORDER►S
USE
' APN: 773-274-009..'....
GRANT DEED -r2w- •z.00 1
The undersigned grantor(s) declares)
Documentary transfer-`tax:,'is $11 00
r�..
XXX)`'(;omputed on' fu11'value 'of property 'conveyea or
Computed on full value less liens and 'encumbrances remaining at t'
((( ) Unincorporated area: time of sale.
� ). City of .
w
and
"FOR A
VALUABLEtCOr1SIDERATION, recei t �� -�
p wni.ch is hereby acknowledged,
COZZETTE G. GRAY, as Trustee, OF__THE COZZETTE'G. GRAY LIVING TRUSS r
hereby GRANT(S) to
' r SCOTTGOP,DON and CATHLEEN L. GORDON, Husband and Wife as Joint Tenants
�+ ✓ the real property in the City of,.County of Riverside, State of
California, described as:
Lot 14, Block 102, of Santa Carmelita Unit No..11, as per map the recorded
r in the office of the Recorder
maps. of Riverside County, page 75, Book _8' of
...
.__..._ _._ Dared_.-Idax_?3
�� •.1.9.9.6_..----=---__.�_ __ ._.----.--- — _: •...: -
State of California
County of Grp �S
On / ):S.S: COZZET
G
RAY; :as ..Truste
-.
before me, S ' P .� %rte.'./ �d-n��•:
eC� 2personally appea ed
fZ: q y _.
personally known to me
For
the basis of satisfactory evidence) otoeben
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),nor the entity upon: THOMAS J.JEFFERSJR.
' s
behalf of which the peros) acted .executed a •" COMM.#.99J879
1 r� + ">' Notary Public = Californlo .
the instrument.
• , , LOS ANGELES COUNTY
V Comm. Expires MAY 25,199
WITNESS my_.,:hand ffirj,gl. Boal
Signatu
��pp1�S_ " /Z (This area for official notarial seal)
�4 AR
MAIL TS!'AT'E S TO : ' J J
0
:�.
0