0210-123 (BLCK)FF--
N"W
O � M
W'�
6 Z t�
(D0o
W W
(-
0)
Z
ON
U rn
O_ a
Z
T Q O
0 LIJ
JJ
mUU
O
d
U-) H
It Z_
co 5
C)
Q
J
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptdr 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
Date 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 license
contractors to construct the project,(Sec. 7044, Business & Professional
Code). 1'V
() I am exempt under Section , B&P.C. for this�eason
,Date /d J! b -O✓ Signature of Owner
,.
—11 11
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, forth0
performance of the work for which this permit is issued. H�
( ) 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 t e Labor
Code, I shall forthwith comply with those provi ions.,
Date: 6,� ^ U-12*Applicant
Warning: Failure to secure Workers' Compensation coverage is/Inlawful 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 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 inspec a0n purposes.
Signature (Owner/Agent is ! _ Date P7 '. 117
' BUILDING PERMIT PERMITq
i321L-%W
DATE VALUATIONS fl LOT TRACT
ADDRESS 'e{'j�i�l+
JOB SITE
APN -
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
SEM 1VVWM
OVNER -13U71DER
IRKWHOMUR
LA QUWfA. CA 92213
(� c'UR
USE OF PERMIT
1
2001Y"OAPDX' 7 W6lL 4f10 tri+' 6' OAKUM 'abfR.IrInD LF J
001M.0RA,T ON 2'R WfAl N WO(Ty(TH 6! OAR NN WALT... LI, PRk CV Y
;„MNMRD &CDD .tLP1'TiL'.)V T) PI AM.
6 IFF. WAM, 670.01011 JF
5 F1'. WALL 200.00 JF
E8'.I D&NI: CY.1l'1' 0.F CONSTRUC1'°Cf'3N
1'1t'faffr FEE MADdT4RY
CONSTRUCTIONFEE
�J.C1 � , :II, J
CITY OF
L A QUINTA
FINANCE DEPT, .
4 .
r`
RECEIPT
DATE % ^
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 Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS Z
POOLS - SPAS
Steel
Set Backs//I n ,_ /
Footings / vlll//J
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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 est
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.I.
Smoke Detectors
Temp.. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
G l ✓G ��
�—
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may. be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.. ,
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcomractoi, dhly-undcr limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building s,
permit, erroneously implying that the property owngr is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760 777-7012
=770 1 /6
OWNER'S SIGNA ATE `
S� av G Z 1411 ' , 4i ,ae-e
PROPERTY ADDRESS
0210- lZ3
PERMIT NUMBER(s)
or
CITY OF LA QUINTA
i .
' a
vo
q n�
v
cl
i
Q
I�
Uc�
'o
c 00 3
zU E d U
c E Z
to X
UwO
f ;
4V
6
11 X 17 PRMR80 ON NO. 100011 CLBARP111Nf • !
644 r£
BUILDING & SAFETY DEFT.
APPROVED
FOR CONSTRUCTION
DATE_IO (f JZ BY
{
VRE-INSPECTION FEE OF $30
,WILL BE CHARGED IF THE APPROVED
PLANS AND JOB CARD ARE NOT ON
IHE SITE FOA A SCHEDULED
INSPECTION.
.NO MEPTIONSI
' t<7G0
t
i.
f•
DIqe�
r
4L
4'_lv 41.
T t"
t • -t
r
SCALE: �INl4iiGH/J�
APPROVED BY:
DRAWN BY
! "
r.'
DATE: /o ���-C7.�
REVISED
F
r
r
.
1
DRAWING NUMBERCA
j
j
f
JUN 02 2006 15:32 FR FATCO RJUERSIDE
.4L7.
r,l+ W
1 1''• i', \y i••LI GO
nEceAC1110 r+1:C►1FstEo Br.
AM VMN RECORDED. WA TO
Jus" a. Lyl�Ofl
(jli3sr�ss�wt�z vv 17,
p�RCEt I+o. 773.331•-006
dn rrn.E ORDER MO 1$16056
V ESa:RvrlNo: 6366 -ST
GRANT DEED
FOR A VALUABLE CONSfDERATION, receipt Of whidi is ante&/ 0Www6d9W'
909 274 9316 TO.97777112 P.05
DOC >a 5000-376002
ggMf26e 90:0" FMa:l. W
pope 1 of 1 Doo T Tu Fold
IM.or� In p/Ilolal Ro�M
cw..ty or illvoroAde
Ro�Mor, Canty
_lark l9owdef
r i s v -
1?le urdersigr>ed Gfarllor(6I� that the DOCUMENT TRANSFER
TAX l5:
$234,30. oavrny i C�' conveyed, or
�Corrtiputed on me fdt value of the �tereat of proPertY
_Cprnpu6e4 an tfle ftio value Wss the value d liths a enculnb(wuss
fema�ing thereon it U+e time of sate.
OR transfer a EXEMPT from tax tw the foumttV reason:
setty J. Cr dwd
I�
Aefeby GRANT($) to Justine S. Lyecb r a MICried wwan as hAr sole and separabe'PrWertY card
Seth Sebastian moffman, a single mill, as Joint Tenants
alt that real property sit"ud In the City of La Q4nt3 County d Riverside, Site of California, described as;
Lots 19,20,21 and 22. BlOck 145 Of Santa CenT"s at Vab La Quina, Unit Nm 15 03 per map W file in Book
19, papa 92 of Maps. ReCwds d RfVMide County, CaNtomla."–
Dated swwrbw 1. 2000
STATE Cif CAL1!' i
CLNA" C
ON D e.1on RrillL Betty J. C do t
/ld.y ira?r+�f 'red
�w�.kras.io �w Joe posed o w- on to W04 or "46%dw7 ov16.rM) bewi K t ack
b a M ,ahoa� mbecrbod w w rtkh rrourr� ra AAw�r1f
fnepo M =— w w Mow r+ �AorMr . •�
wavbb ���• on M kreiorMM
.M Ileoor� orb rrely �r carr/ teor" dw ow. wabd
wrr E3t�� olrloM wi
"L TAX STATES TOdw
Jusrine 9 'L nC •tab DAw. Adwton• CA 911121
Description: Riverside, CA.Docurnent-Year.Doc1D 2000.376892 Page: 1 of 1
Order., 00-06-02-2006 03-23-27 PM Comment:
wom F. tUl w"
Co.rlrrssion a 12�1t1•
Iw
rAtl� CO�wM
r+rOvw+►Bc1�rRO1�1m1
Description: Riverside, CA.Docurnent-Year.Doc1D 2000.376892 Page: 1 of 1
Order., 00-06-02-2006 03-23-27 PM Comment:
JUN 02 2006 15:32 FR FATCO RJUERSIDE 909 274 9316 TO 97777112 P.06
RECOROma PAOUIMTm BY
AND W"F.h ACCOAMD. MAL TO
j4mm R LYmn
DOC a 2000-376SOIL
68/76/26W M:aart fM:7f•M
rawl.f�
Moores An offlolal K.d♦
Carnty of R1wr.1M
Day L. Droo
fmIwM•, County Clark l Recorder
RAW
w�essoRs' t h )�7�,-006 TI» 1Md�d 6�f�� ms, declog that the WCL EKT TRANSFER
TAX & v
T111 E ORMA NO $46VA i Calm* i city
_=rVu O on V* fW vakle d Ir a itMest of o►op eft wrrrYw0. Ot
ucptow wD _=raged on U ke vakls lass Im value of ions no a ameranoes
csn%UWV thefeW al the tkrla of sale
QUITCLAIM DEED oR ft11W I, vfEYPT k" to t4r Vw 6-P- faoefon.
FOR A VALUA&X COMSIDERAPON. Wald al Wrdf s hwwbf aetewrbdp L
Cnadn A LYAO W*b" a! Ma Drantee Iweb ET
iA
hwoof RORSES, RELEASES ana QWTCy.AWS a
heeling B CYKt+- a maMwd women as nwf !tole wn0 aeParw Drowsy
aY Nut rssl feft,WTY sawtwd h ft Cly a Ls Outrea Count' DI R6WSi G SIs1a d Cskb . deunbed as loos 19.20.21
aPd 22. ebeA las d 3r" Cams" d YOM LA OuVAL Unl No, 15 no paf map on Me :+ sook 1A. pow 02 of Asap&.
Ramrcm of RN&I C9 cowry Gaamm.
Duo 360rrbr 20, 2000
SIATE OC
COVNTY
_ . botay rmw, ea www ftowOd
0*rles A. ,¢yarn
erdrlY�boWa+r (d 04+M r eh re M 1.w d �1 e+ei�sl
et' w lye» •►err �M >P M �� NfMwo MI
.j1 O Ra Ott �� tlnl .
f7 ^U.4 N 1V 4'Ur V" 6" d
w nrtln...
YMTt453 iAr P d wed end mw
MAIL ?AX STATEMENI S To-
aro! as aoor a►ad wb"
4�c�
Charles A. Lynch
Description: Riverside, CA Document. Year. DociD 2000.376891 Page: 1 of 1
order.- 00-06-02-2006 03-23-27 PM Comment: