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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
Dated F Signature of Contractor `� �►-
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).
( ) I, as owner of the property, am exclusively contracting 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.
(Ii) 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 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 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? 4 Q ) Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
sliall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
;IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees Jo, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby,,,authorize representatives of4his City to enter upon
the above-mentioned property for inspection put$oses.
\a
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Signature (Owner/Agent) oM `5 Date'/
a
BUILDING PERMIT PERMIT#
DATE ^ / VALUATION LOT 01(L*�-282 TRACT
17
JOB SITE -^ ^-^
APN
ADDRESS
52-•120 itUMBROW.M.IMM
773-23.1.-W6
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TIACTFIC TlZADES COWLTIRUCTXt:lN
13A.CIFIC'iWO," CORMUC'h:ON
1739 3 :1:.'��M01.13
1739 0 TREMOW,
R OC -SA dSWE CA 920%
8 OCRARMA'T, CA, 920 A :.
(pc_))9;51 •C10 rE t."BU 1955
USE OF PERMIT
SING --LE FAMtiM
.Ids - PI"i23 IT 0025 NOT 111C1AJDX J31. CK. WA3.,I. POOL• & AOR
I)MVEWAY APPROACH, O,.r MASTER UAN FEWP H.
�Yl Ri•"T (;OAik1YMICTICI i9$2.f�13 $i�
PR31?C1' MATIO 10$.00 S1+
$ P'T,WOOD MICE 200.041 1,F
d'.)_A RAOF, 460.08 SP
E:et;Y.MV.7.As,.17.1) COW 10F'` CONSWITC-11,00
97,19.7fm .s.
F .M11� IM SUMMARY
PEE PEPOSF'1' .101.000.439^3143 4230199
Clow.111TRUCTION IT'S S585.38
PLAN CHFICK FEE 101-000,439-318 14301.
jtR.ECH;tA LAICAL I+'0.1.1 101,;000-421-000 $53.50
X,X3:3); IAL.F'9Y, 101-000.420-000 S1OSIVY
;Ai:�`1.bbDAI�1Nt� 3�k: i 01-�abc�a i fl-4?04 $11 U.'Z5
9TF ONG MOTION RK -RMID 101;-000.241,4300 $4.72
CRALM14t:1.FRIB 101.-000-423-000 $20M
DILN i�.��sMeR T1*�i1'ACT M $1,907,00
3R.aiMSEE F}t.rAN 101-000- 1 -?+3.3 $100.00
uSU'i'l-TMA%aLrfs}i7SI:1:Z.1:3�C`,i`10 ANDKA C*MCK
fl?1;iJ.e�r$
; M'3 1 -PAID to KS!
42513.00
MAY 2 5 2001
RE
EIPT j'I
&Al id.
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall 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 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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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.1,
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
V I,
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CITY OF LA QUINTA
�f 5� BUILDING & SAFETY DEPARTMENT
OF 1 777-7012
INSPECTION REQUEST LINE
777-7153
Owner
Contractor
Permit Number
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
JOB ADDRESS �►� �c s<�""
4tR5&v ti
TYPE OF INSPECTION
DATE INSP.
FOUNDATION & SETBACK
�t
FOOTING STEEL $Z
MAIN GROUND SYSTEM
GROUND PLUMBING
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
i .v'
HEATING & VENT - A/C
FIREPLACE
ROOF
p
BOND BEAM
O.K. TO WRAP
• !O -O
GROUT ❑ 4' ❑ 8'
FRAMING
1 7
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
DRYWALL INTERIOR .O
EXTERIOR LATH .Q
POOL PRE PLASTER
POOL FENCE & GATE
SEWER SEPTIC TANK s e.9
FINALS
ELECTRICAL D
PLUMBING
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS 99
JOB COMPLETED 8
TEMP POWER i _W ( I/
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING
ls'aY+�',�y'f4�5�"L"4�C:�+Y"v"'_.+„-�. vY 'Y�rP -y .�...-:vC �. � { ,r�.i--.��,.� ���.wV �w✓.4 ,�„ w.r��.�.i'^"-�- ^
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P.O. BOX 1504 APPLICATION ONLY
Building 5-Z y �78
-495 CALLE TAMPICO0,4�
Address 4XQUINTA,CALIFORNIA 92
253
Owner GI)_ f _.
Mailing
Address
City Zip Tel.
Contractor /k
p
Sate Lic'Cit
&tCla sif. , (�/ �` g � I Licy#
Arcn., tngr.,
Designer
Address
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I'am licensed, under provisions of Chapter 9 (commencing with Section
7000) of Division 3' I the Business and Professions Code, and my license is In full force and
effect. \ /ti -7— .t J
SIGNATURE +�� �`N I�/ 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 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 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
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, ora certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
r7 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 (E100) 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, alter 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 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 sof this city to enter the above-
mentioned property for inspection purposes.
Signature of adplicant Date
Mailing Address
City, State, Zip
BUILDING: TYPE'CONST. OCC. GRP._
7
A.P. Number C 3, —.2 -5 / 6 a / `�
Legal Description Z6 T /,7
Project Description
Sgq
Size
No. No. Dw.
Stories Units
NewW Add ❑
Alter ❑ Repair ❑ Demolition ❑
"1-2-4"
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
- LrjU U O
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
Li I
TOTAL
REMARKS
CITY OF LA OUINTA
FINANCE DEPI
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 Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Notice:
Document.Cannot Be Duplicated
Date 5/25/01
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
No. 22047 Jurisdiction
Own,,NamePacific Trades Construction
No. 52-120 Street Eisenhower Drive
City La Quinta Zip 92253
Tract # BLK96 Lot # 17
Type of Development Single Family Residence
Comments . .
APN # 773-231-006
La Quinta
Permit # 0105-282
Log #
Study Area
Square Footage 1,382
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. Government Code 53080 in the amount of
2.05 X ; 1,382 or $ 2,833.10 the property listed above and that building
permits and/6i Certificates of Occupancy for this square footage in this proposed project may now be issued
a
Fees Paid By CC/ Temecula Valley Bank - David Miller Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Paula Ruiz
r
Signature
V.
v` -r
Payment Received $2;833.10
Check No. 15757
NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify ypu 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
:ollect them on the Distrfci('s)(s') behalf, whichever is earlier.
r
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original 'Building Dept./Applic"" Copy - Applican eceipt Copy - Accounting
01/09/01 10:25 FAX 17608049062
REC.ORDI,ri REQUESTED BY;
AND WHEN RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL. TAX STATEMENTS TO:
William Thomas Buffin
Power Brokers
D.O. Box 134
La Quanta, CA 92253
COMMONWEALTH TITLE
oo—
. � t
SPACE ABOVE THIS LINE FOR RECORDER'S USE
Grant Deed A.P.N.
The undersigned grantor(s) declare(s):
Documentary transfer tax is $
computed on full value of property conveyed, or
( x) computed on full value less value of liens and encumbrances remaining at time of sale.
( ) Unincorporated area; ( ) City of
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
Martin Klein
hereby GRANT(S) to David Ross Miller, a Married Man
as his sole and separate property
the real property in the City of La Quinta
State of California, described as
, County of Riverside
773-231-006
[a 002
Lot 17 of Block 96 UniC No, Santa Carmelite at Vale La
Quinta, as per map recorded in Book
County, California
Dated April 9, -;2001
State of California )
County of _)SS.
On before me,
,personally appeared
Martin Klein
personally known to me (or proved to me on the basis of satisfactory
evidence) to be the person(s) whose name(s) islare subscribed to the
within instrument and acknowledged to me that he/she/they executed
the some in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the Instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and ofricial seal.
.Signature
MAIL TAX STATEMENTS TO, game_ s ,b--xe
, and
Pages mf Maps, Records;of Riverside
Signature of Grantor
Martin Klein
Form 3196-1 (6-94) THIS FORM FURNISHED BY COMMONWEALTH LAND TITLE COMPANY
RC DISTRICT - PLANNING REVIEW FORM
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 -120. -Eisenhower Drive
APN 773 - 231 --
LEGAL: LOT 17
006 CASE NO.: 2001-469
CHECK AND APPROVED BY:
BLOCK 96 UNIT
Fred Baker
DATE:
S.C.@V.L.Q.
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
Consistent with MDG on file (as
applicable
MDG filing required ( 5 filings since
9/3/98)
XHI
IT
Architectural variety within 200 feet of
the surrounding area:
Colors
Materials
Architectural design features
JASE
40.
Other Requirements:
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: 52-120 EISENHOWER DRIVE
Use Classification: SFD
Occupancy Group: R 3 Type of Construction
Owner of Building: PACIFIC TRADES CONSTRUCTION
—��
Building Official
vni
Bldg. Permit No.: 0105-282
Land Use Zone: RC
Address: 1719 S. TREMONT
City: S. OCEANSIDE, CA 92054
By: STEVE TRAXEL
Date: 09-06-01
POST IN A CONSPICUOUS PLACE