0201-209 (SFD)LICENSED CONTRACTOR 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 is in full force and effect.
License # Lic. Class Exp. Date,
�IMS3 1 07/3112
Date `� - Signature of Contractor CYC ec �---
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: 1,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, Business & Professionals Code). „
( ) I, as owner of the property, am exclusively:, contracting with licensed
contractors to construct the project (Sec. 7044,' Business & Professionals I
Code). f
() 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. r
( ) 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 VU)4 Policy No. 1210"" -Di
(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�provisionskof Section 3700'of the Labor
Code, I shall forthwith comply withtthos" provision§. Jfy
Date: Applicant
Warning: Failure to secure Workers' Compe(�sation coverage is unlawful and
shall subject an employer to criminal penalties\and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person Be
whose request and for whose benefit work is performed under or pursuant to.
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and',void if
work is not commenced within 180 days from date of issuance of'such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) _:., Date
/BUILQ[NG PERMIT PERMIT#
DATE %% `! VALUATION LOT `! TRACT
!/T /Id -e - BLX 152
JOB SITE APN
ADDRESS ij2-ft+$M7,,i�,AAIM.E.A 7734R$-022
..„
OWNER
CONTRACTOR/DESIGNER/
DA'V.I O ., 1KLLI,:€ a } PAX-IM01 TEAM, COHM-RUCTION
171 n 9}ULral 1'r w-0—iT 171 S 3 b k' FEMMY.
IT
a``w� (i�G�}9f��•Ot� 9 Cid 3935
USE OF PERMIT - e (f f' I , •- • r �'/^'•� I •
W.d.+IC�3�; r.,4/bll'.'C 1, 3J'F. L17 -1L.3 INU, �
irl2• I? ;2 DoIgs X09'; JG.f.ilrmgxC ,, K, "R.A:I.J, I''001_, 0R 0K,fYKWAY.
'1 C'T CONS'. Gafpw 1,431 � S1�
9 C:iilf+ATli 'bits,i>il SP
(� Ia4ljt.!C'Ab�.i ':3IQ,13i! €ITS'
3 t'fJC"aJq
Win rill IP
Slab-1'0'l1f,I., CONEI Rf-iMOA+i AND PLA.1`1' 00C�r tt.
LESS PPE -PATE) ATE) TI !: S
JAIL
®F
YXIII I ur FKAS DUlf AM
11
$3,43034
4250,00
;9215MANTED COR' Olf CONSTRUCTION
890.2:".10
p ' mmuA"
C0113t"►tUCi'IM4 PE-
101.000-418.000
094,30
P1:.104 ?IKE
:101-01;70439_318
MO. II
i
N9F:t•`II.IANICIAL 1+1',ie
101,000.427.-000
U0100
?zC191t,17,9
101 -000-420-000
$129.44
S LIJ,t44�3Tfi1IM,
101-00041911000
VA 101171
aT1R,UNd :jylU11CM FEE d RMSUP
T 09 w 0003 1 00I#
$8.93
MALiINOIEE
101-000-423-000
1120.00
Di±ii'E•W11??uR.IMPACT MUZ
Si,4t,7.00
MCME PLAN
101-W-0-441-345
$100.60
"IF, DEPOSIT�
1ii1�i4i30���-:311w
4250100
Slab-1'0'l1f,I., CONEI Rf-iMOA+i AND PLA.1`1' 00C�r tt.
LESS PPE -PATE) ATE) TI !: S
JAIL
®F
YXIII I ur FKAS DUlf AM
11
$3,43034
4250,00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR _
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- 3 OZ _
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air _
Roof DeckExhaust
Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Z? o z �
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
.lpY
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
0—
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
ewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
_
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures-
ixtures-Main
MainService
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final—
Utility Notice (Perm) QG;
X12
Iia-
P.O. BOX 1504 APPLICATION ONLY
Building 78-495 CALLE TAMPICO
Address �G ^-rte i ✓'J l .�/7/�.��/�.�'� LA QUINTA, CALIFORNIA 92253
tiZo� - Z 0%
/ /// " 1/", /f//,,- s
mantng j
Address /-7
City Zip Tel.
Contractor /
Address
City lZip Tel.
State Lic. I City
& Classif. X 112 Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 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-: 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, 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 1 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
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.)
11 I am exempt under Sec. B. 8 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 if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thF 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 she 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 if work thereunder is suspended for 180 days.
1 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 slate 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
BUILDING: TYPE'CONST. OCC. GRP.—
A.P. Number -7 7 � - 7 > "- e- Z Z—
Legal Description �,%• /�L/� / Z
Project Descriotion
Sgsi t. i- No.
/
Size %4 /2- Stories
New m/ Add ❑ Alter ❑
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
No. Dw.
Units
Repair ❑ Demolition ❑
AMOUNT
7 1 �
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date P-eiDait_
e
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING
Notice:
Document Cannot Be Duplicated
Date 1/28/02
No. 22865
Owner NameDavid R. Miller
No. 52685
city La Quinta
Desert Sands Unified School District
47 -950 -Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Street Avenida Herrera
Tract # BLK 152 Lot # 9
Type of Development Single Family Residence
Comments
Tract Construction 1421 sq.ft.
APN # 773-293-022
Jurisdiction La Oninta
Permit # 0201-209
Log #
Zip 92253 Study Area
Square Footage 1421
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect 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 time due to the following reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to G=overnment Code 53080 in the amount of
2.05 X 1,421 or $ 2,913.05 the property listed above and that building
permits and/or Certificates'of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By CC/Capital Bank of North County - David R. Miller Telephone
Name on the check
By Dr. Doris Wilson .-
i� ,
Superintendent
F
Fee collected /exempted by Nicola Wong Payment Received $2;913.0.5
Check No. 086015
Signature W ma
NOTICE: Pursuant to Assembly Bill 3081 (CHAP 549SUATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy,for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
RECORDING/
REGUE8TED fav: {
AND WHEN RECORDED MAIL THIS Dr;ED AND,
UNLIESS OTHERWISE SHOWN BELOW, '•
MAIL TAX STATIM _NTS TO:
David Ross 'fillar
1719 S. Tremont:
S. Oceanside, CA 90254
SPACE ABOVE THIS LINE FOR RECOPDER1 USE
The urderslprted grantor(s) declare(e): Grant Deed ARA 773-293-022
Documentary transfsr tax is 5
(• Xx) computed. an full value of property conveyed, or
( ) Cornouted on full value less vatue of liesrts and eneumhrences remaining at time of sale,
( ) Unincorporated area: ( ) City of .
and
FOR A VALUABLE CONSIDERATION, repelptOf which le hereby eckrowledead,
FRED & ULA OLDS
hereby GRANT(S) to DAVID 'ROSS MILLER, a married mart as- h:U& •sola and. separate property
the Peal proparty I,n the City of ,r,$ Quin [a Count o1
Stats of Q911017118, described as y Riverside
Ze>:.of Black 152 2Unit AIo, , Santa Carmelita at Vale -La -Quints,
as per map recorded in took pages d -f Maps, Records of Rivirside Counry,
California
Dated. December 12, 2001
State of Celitomia
County of
)SS,
On b9r'Pr9 me,
Persanplly Rnewn to me to., proved to me on Me basis of 0etlsfaciory
evldenec) to be the perscn(s) whose name(8) Ie!_ar9 9ubscited to the
within instrument snt: acknowledged to me that help'*they executed
the varne in 1`110*0114slr authofted capacity(lea), Alta tnet by
hWMe;/ihNr slpnoture(s) on the inrtrvment the paryon(e), or the snUty
upon behalf o' whleh the person(s) Adod, exe;cuted•the InetNment.
Signature of Grentor
FRED & ULA OLDS
WITNESS my hard and official seat.
Slaneatura
MAIL TAX STATEMENTS TO,
_i
i
lu/i A 6"!L'"0J 81VQj a6.J,;,3 l0iic 7,1 NaCl
r
MVFF
JAN -/4.,%:u
RC DISTRICT - PLANNING REVIEW FORM
CITY OF LAQ 11N T;,
PLANNING DEPARTMENT
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove
Residential) District per Section 9.50.090 of the Zoning Code. Its purpose is to determine:
1) that the proposed house design does not duplicate the same architectural style of any
house within 200 feet of the applicant, and/or 2) if there is a need for the applicant to file for
Master Design Guidelines. If the applicant does need to file a Master Design Guideline, please
transmitted this information to the Building and Safety Department as part of your correction
list. Please attach additional explanations as necessary.
APPLICANT PACIFIC TRADES
SITE ADDRESS 52-685 Avenida Herrera
APN 773 - 293 - 022 CASE NO.: 2002-606
LEGAL: LOT 9 BLOCK 152 UNIT S.C.@V.L.Q.
CHECK AND APPROVED BY: wally Nesbit DATE:
Inform the assigned Building plan checker upon your assignment to this case. The CDD
Executive Secretary maintains a log book to track applications and assign case numbers.
REQUIRED ITEM Y N COMMENT/CORRECTION
Verify legal and APN information /S ow—�IT
Consistent with MDG on file (as
applicable /\11A
MDG filing required (5 filings since
9/3/98)
Architectural variety within 200 feet.of
the surrounding area:
aL
Colors ? r �)/ /�✓�(�x�lI7N(� �/z�¢
Materials
Architectural design features &r )ro ied b ,-.
Other Requirements:.11 City Council
Initials = -
ase lo.
xhibi
P(Witj Conditions gj.-;� `r
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SINGLE FAMILY DWELLING
Occupancy Group: R73 Type of Construction:
52-685 AVENIDA HERRERA
Owner of Building: DAVID R. MILLER
r --
Building Official
Bldg. Permit No.: 0201-209
Land Use Zone: RC
Address: 2551 STATE STREET, STE. 1.11
City: CARLSBAD, CA 92008
By: GARY SHOWALTER
Date: MAY 24, 2002
POST IN A CONSPICUOUS- PLACE