0211-010 (SFD)U)
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LICENSED CONTRACTOR DECLARATION .
I hereby affirm under penalty of perjury that I am licensed under provisions c
Chapter 9 (commencing with Section 7000) of Division 3 of the'Business an
Professionals Code, and my License is in full force and effect.
'License# Lic. Class Exp. Date
.588622 NIA. 02/2W
,Date �%�� u Signature of Contractor /A
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor'
License Law for the following reason:
( ) I,. as owner of the property, or my employees with wages as their sol
compensation, will do the work, and the structure is not intended or offered fc
s IeY(Sec. 7044„_Business•& Professionals Code)
(r� �`I, as cio,'wne� of the propertf, am exclusively contracting with license
olitractors, t6 construct the project (Sec. 7044 Business &Professional
Code). :y v
O I am exempt under -Section r B&P.C. or this reason
Date-Signatur(Pof Owner
W l_AJW 4
WORKER'S COMPENSATION DECLARATION '
I hereby affI' m under penalty ofperjury one of the following declaration;
O I have�&d will maintain a cgJt;tificate of consent to self -insure for worker:
compensati6�n, §_provii d for ISj~ Section 3700,o`f the Labor Code, for th
performance of -the -work for which this permit is issued. ?
( ) I have and will maintain workers' compensation insurance, as'required b
Section 3700 of the Labor Code, for the performance of the work for which thi
permit is issued. My workers' compensation insurance carrier & policy no. a_ re
Carrier ME3dlP•I' Policy No.
(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 issuec
I shall not employ any person in any manner so as to become subject to th
workers' compensation laws of California, and agree that if I should becom
subject to the workers' compensation provisions of/Section 3700 of the Labc
Code, I shall forthwith comply with those provisions.
�Daiie: ? •� Applicant
I'// / / t
1A(/( f -
Warning: Failure to secure Workers Compensation coverage is unlawful ani
shall subject an employer to criminal penalties and civil fines up to $100,000, ii
addition to the cost of compensation, damages as provided for in Section 370,
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safet
for a permit subject to the conditions and restrictions set forth on -hi.
application.
1. Each person upon whose behalf this application is made & each person a
whose request and for whose benefit work is performed under or pursuant b
any permit issued as a result of this applicaton agrees to, & shall, indemnif
& hold harmless the City of La Ouinta, its officers, agents and employee:
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of sucl
permit, or cessation of work for 180 days will subject permit to cancellatior
I certify that I have read this application and state that the '.above information i
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 upol
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) f Date
If �' BUILDING PERMIT PERM}T/f
d DATE VALUATION LOTS^�g� TRACT
_17 BIX 229 U'22
JOB SITE APN
ADDRESS 53-640 AM.1 A HERPEFRA, 774 -124 -OM
OWNER CONTRACTOR/DESIGNER/ENGINEER
SANTA IZOSA DE .CJPMW T,. MC 1M03 VE BtMXS.ERS '
S P.O. ROX 11335 PO BOX 11335,'PALM �)va°�-�tT CA 92255
PKIA;,.1ESEW CA RM -10 CA 92201
e
(760)485-7657 C"9 1.4. 4 360
r
USE OF PERMIT
S
1423 3QFT. RIWDGP11CF PM -41T DOES NOT INCLUDE I• LOCK WAL-1,4
MCM% POOL OR VA,
rr 1=7.�
TRACT CfJNi;` RUCTION 1142100 8?
s PORCH/PATIO 63,00 Sit
GAFiAMUCARPOR7: SS2100 SF
Y
s
ESMU )TED COST Or? CONSINiTeC7TtON B�,S��1;i3i►
PERMIr Fn SIWMARY
CONSTRUCTION FEE -.101.010-0-418.000
I' PI.. 14 CHECK "1E 1(3Y-QG(?-�l3g-31 S �S03.flfl
FEE DEPOSIT 1,01-000-439-318 $iSU.a9
r MECHANICE+,1, FEE 1.01-000-421-000 $i36.fl1!
V L,ECTRICAJ, f W •101.660.420.000 $109,35
PLUM#1i'AiO k1% 101-000-419-000 W10.75 '
i S1'Fc,om 1V10`rm. FRE' AFAM 101.000-2411.000 so, *09
i GRADING FEE 141-000-423-000 ZIS.itd1
DEVELOPER IMP'AC`l.'FEr �3,4►�9,a0
PRECISE PI,.AN 141.•000.441-345 $,i Hi3.00
t
SUB -T OTAL CO 10"MUMON' AAIB PLAN CIMCK .$3,960.87
1223 PIR&PAID EMS 4250.00
Q
f d TALS : FURAMP"Ji EES DUE NOW $3,710.87
APR 22
1003
C
i MAN E OE TA,
RECEIPT D BYDATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
'
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath _
Drvwall - Int. Lath _
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
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 APPROVALSGas
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 Test p
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
Final
Utility Notice (Perm)
CERTIFICATE OF COMPLIANCE.
Desert Sands Unified School District
47950 Dune Palms Road
Date 4/22/03 La Quinta, CA 92253
No. 24351 (760) 771-8515
Owner Santa Rosa Development, LLC
Address P O Box 11335
City Palm Desert Zip 92260
4�'3�,�lEDsc�o
BERMUDA DUNES r
RANCHO MIRAGE (:;I
INDIAN WELLS
PALM DESERT y
V LAOUINTA
,)IQ 0 O ':
O J
APN # 774-124-008
Jurisdiction La Quinta
Permit # 0211-010
Tract # BLK 2291.122 Study Area
Type Single Family Residence No. of Units 1
Lot # No. Street S.F. Lot # No. Street S.F.
Unit 1 17 53640 Avenida Herrera 1423 Unit 6
Unit 2 Unit 7
Unit 3 Unit 8
Unit 4 Unit 9
Unit 5 Unit 10
Comments
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patiostwalkways, 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 1,423 S.F. or $3,045.22 have been paid for 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/1st Bank - John D'Ambra Check No. 68005
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by S4@ron McGilvrey $3,045.22 $0.00
Payment Recd Over/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 Copy - Accounting
RECORDING REQUESTED BY:
AND WHEN RECORDED, MAIL TO:
Santa Rosa Builders, Inc.
PO Box 11335
Palm Desert, CA 92255
THIS SPACE FOR RECORDER'S USE ONLY
ASSESSOR'S PARCEL NO.: 774-124-008 ie undersigned Grantor(s) declare(s) that the DOCUMENT TRANSFER
TAX IS:
TITLE ORDER NO.: $ County $ City
ESCROW NO.: XX computed on the full value of the interest of property conveyed, or
— computed on the full value less the value of liens or encumbrances
GRANT DEED remaining thereon at the time of sale
— OR transfer is EXEMPT from tax for the following reason:
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Jeannine Brannen, a married woman as her sole and separate property
hereby GRANT(S) to
Santa Rosa Builders, Inc., a California corporation
all that real property situated in the City of
County of Riverside , State of California, described as:
Lot 17 of Santa Carmelita at Vale La Quinta, Unit #22, as per map recorded in Book 20,
Page 24 of Maps, in the Office of the County Recorder of said County
Dated October 22, 2002
- STATE OF CALIFORNIA, }
COUNTY OF Riverside } ss.
On 10-29-02 , before me
Ruth A. Furst , Notary Public, personally appeared
Jeannine Brannen
pfffQRWWA €ia4 w:Rxtkjft (or proved to me on the basis of
satisfactory evidence) to be 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 ), or th6.ent�y upon behalf of
which the person(s) acted, qx6cutedAhe.in tument.
WITNESS mvrhandand. official se
Signature LJ/
MAIL TAX STATEME TS TO:'
Santa Rosa Builders, In(�J
NAME
C �1 L
J annine Brannen
RUTH A F1RST
Commission * 1366930
Z Notary Public - California
Riverside County
QEMYComm. E3iresJul27, 2006
(This area for official notary seal)
11335, Palm Desert, Ca. 92255
ADDRESS
CITY, STATE & ZIP
Bin #
City of La Quinta
Building 8z Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building .Permit Application and Tracking Sheet
Permit #
Project Address:
0%%-ner's Name:
A. P. Number:
7]Cit\-.
Address:
Legal Description:
ST. Zip:
Contractor:
FTelephone:
Address:
Project Description:
City. ST. Zip:
�/✓ SS
Telephone:
/✓V�%t'C✓���o
State Lic. # : Cit-,- Lic. #:
Arch.. Ener.. Designer:
Address:
Cite. ST. Zip:
Telephone:
Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Proiect:
APPLICANT: DO NOT WRITE BELOW THIS LINE
k
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
uss Calcs.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2"" Review. ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SAI.1.
H.O.A. Approval
Plans resubmitted
Grading
IN' HOUSE:-
'"' Review. ready for correction issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees