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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
395754 B1 C9 06/30121
Date S' "7_4
Signature of Contractor
OWNER -BUILDER DECLARATION..i
I hereby affirm under penalty of perjury that I am exempt_f rom 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). s
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
Thereby affirm under penalty of perjury onerof 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensattiion insurance carrier & policy no. are:
Carrier STATE FUNp Policy No: 229-00 UWI`P 0011090
(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 Se tion 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: • l� 't `�oOApplicant
Warning: Failure to secure Workers' Cor/pensation 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 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 fo -inspection purq'oses.
Signature (Owner/Agent)
Date's` —Z
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0004'21.2 TRACT
BL210
JOB SITE
APN
ADDRESS a-2:5 EYSE.1` H0W DIMLE
7 J4 -0&S-015
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LA C LTIN'1'A PARWERS -
PAS.`' CON 2.UCnOX CO
P.0, DOX 134
525995 AVR?'.1` R)A�i MQYA
LAC)IJINT.A CA 92233
LAQ-U- Tk CA 92233
(760)561.3021' CBL# 5537
USE OF PERMIT
0%h'C,11.£? 1•'1}.h�l�CL:�1'�'Vi:�:1:.,T.127C3
SM -PERMIT DOES NO'i INCLUDE BLOCK WAILS 09. POOL
v.
TRACT CONSTRUCTIOIN 1,3,5, 3.00 9F
PORCHIPA'T10 113.00 Sir
1
0APLAG ICARPOR.T (8F) 9,408.00
3 Irf, WOOD MCE t - 300.00 L F
FSITViATLD COS' OF COP1SINT3C:'T ON.
CONSTRUCTION YUK 101.000-4113.000 $581.00
PLAN C HEC k FEE 1014-000-439.318 , $014:26
1EC'i1�1�IICAL FEE 101.000.421-000 $60,00
ELECTRICAL FEE 101-000-420-000 20-000 $ 60.63
nt7mmC31• k 101.000.419.000 $110.73
,
STRI.3140 MOVON FFE - MID 101-000-241-000 $3.63
ORA011413 FErtl 101-000-429-000 $30,00
I)EVF1LOP .P1. !MPPCT F.EF• $1,91~7.00
PRECISE PLKtq 101»000.441.345 S100.00
ME DEPOSIT 101-000-439-318 •�a�o.00
STIP, fOIAL COA1,rDAUC12nN.AND PLAY C1Ii?M
$3,396.21
Liam PZo&PAID FEWS
-$250<00
+'J'?"AL PERWIrI+"EE5 DA, NOW
$3,14-,:27
r•'
RECEIPT
DATE
BY(
DATE FINAL ED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION y
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
j
Underground Ducts
Forms & Footings
2,4,100
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Qs g
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- a 7)O
Drywall - Int. Lath
— pp
ON 4
Final
Final W4 &0 1 f
BLOCKWIM A PROVALS
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
p
Heater Final
Water Piping
j 23 8�
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.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) �tqp
COMMENTS:
TA41YI
APR 14 2000 4
LA
` u1N ` P.O. BOX 1504
JLA 1TY Q' Q 78-495 CALLE TAMPICO �PPLI ATI N ONLY
Building
Address LA QUINTA, CALIFORNIA 92253
� � - � �.r Gf � �',cJ,l�-hf.J _ //
Owner
BUILDING: TYPE'CONST. OCC. GRP.
Address . PV
City Zip Tel.
/-A
Contractor /
J Z- a t✓ a A/100 L
ity lZip
State Lic. City
& Classif. -, s4 Lic. #
Arch., Engr., /
Designer C✓c <t Sl r�.vl► l-, jl �.
Address Tel. -
C -7 t"D
City Zip State
1A to .4r10 A 12..-7_t't Lic.#
' LICENSED CONTRACTOR'S DECLARATION
I hereby alfirm that I am licensed under provisions of Chapter 9 (commencing with Section
7(X10) of Division -oVthe Busines and Professions Code, and my hcen a is in full force and
effect. � f4 _ z0yo
!C A � MM
SIGNATURE �..�� -� DATE
//
OWNER -BUILDER DECLARATION
I hereby affirm,/that I am exempt from the Contractors License Law for the following
reason; (Sec. 703,"1.5, 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 Profession$ Code, or that. he is exempt therefrom, and the basis
for in
ealleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than live hundred dollars ($500).
f: 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 or 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. 11, 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.)
17 1 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, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company - 41,64,0
fiYCopy is filed with the city. ❑ Certified copy is hereby furnrshei.
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.)
Icertify that in the performance of thq 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 shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby 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 a0plicant Date
Mailing Address
City, State, Zip
A.P. Number `T )A - A21,r
Legal Description /_ t P) ., r .AG. 9 / ra
Project Description -. ,,_ L a- i!EA.,-4 l
'? r s - 2 l -;Z A --,-'i
r_Sq. Ft. No. No. Dw.
Size Stories Units
New OV Add ❑ Alter ❑ Repair ❑ Demolition ❑
imated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
AMOUNT
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
Issued by:
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT
s
INSPECTOR
PINK = BUILDING DIVISION
rmit
Sm
Desert Sands Unified School District
47-950 Dune Palms Road
,r Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 5/16/00 APN # 774-085-015
No. 20443 Jurisdiction La Quinta
Owner NameLa Quinta Partners Permit # 0004-212
No. 53-295 Street Eisenhower Drive Log #
City La Quints zip 92253 Study Area
Tract # BL210 Lot # 3 Square Footage 1358
Type of Development Single Family Residence No. of Units 1
Comments
"NOTE: Fees were paid by CC#216381 for $2,770.32 + Cash $13.58 = $2,783.90.
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 1,358 or $ 2,783.90 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&CashNalley Independent Bank/Agustin Paz Telephone
Name on the check
By Dr. Doris Wilson
Superintendent
�y
Fee collected /exempted by Mary Ann L. Borja Payment Received $2,783.90 k
Check No. See Comments
Signature
40TICE: Pursuant of Assembly BIO 3081 (CHAP 549, STATS. 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
mllec them on the Dishict('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
` APR.12.2000 4:07PM COMMONWEALTH NO.721 P.2i2
RECORDING REQOSSTED By; I ,
CHICAGO TITLE COMPANY COMPANY
99.9196KC 97057226
WHZX RECORDED MAIL THIS DEED AND,
UNLESS OTHERWISE SHOWN BELOW,
MAIL TAX STATEMENTS TOi
LENDEL VENTURES, INC.
59090 AVENIDA VILLA ��
LA QUINTA, CA 92253
SPACE ABOVE THIS LINE F01 RECORDER'S USE
J' APN: 774085-015
GRANT DEED .
The undersigned grantors) declare(s):
Documentary transfer tax is $16.50
c, (XXX) Computed on full value of property conveyed, or
( ) Computed on full value less liens and encumbrances remaining at time of sale.
! ) Unincorporated area; ( ) City of , and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
ALICE JEAN HONIG,
hereby GRANT(S) to
WILLI*(- TgOMAS - BUFFIN, 'SAN UNMARRI��
the zeal property in the City of LA QUINTA, County of Riverside, State of California,
described as:
Lot 3, Block 210, Unit No. 20, Tract Santa Carmelita at Vale La Quinta, as per may
recorded in Book 19, Page(s) 38 inclusive of maps, in the offfce of the County Recorder
of said County.
Dated OCbobos 12, 1999
State of Californigg�� �
County of LOS f�N6�ZS I) S.S.
On L
before me, Q
Personally appeared
(or proved to me on
the basis of satisfactory evidence)'to be
the person' whose name' is/A" subscribed
to the within instrument and acknowledged to
me that -)Wshe/Zhao executed the same in
/her/rhei authorized capacity(aesa, and
that by 4 ivr/her/tgie r- signature (s4 on the
instrument the personle*, or the entity upon
behalf of which the person,1w) acted, executed
the instrument,
40ITNESS my han and official a
Signature
MAIL TAX 'BTATSMENTS :
L,16awL8EAL Q
C
ANO CQUMY •o
Mll�nmlpbn Dp, Mo►oh
teal
(This area for official notarial seal)
APPROV
By ..-6i
EXH181'
CASE N
RC DISTRICT - PLANNING REVIEW FORM
This form is to be used by CDD staff for review of single family dwellings in the RC (Cove.Residenral)
District, in' order to determine the applicability of compatibility issues or need to require the filing` of,Master
Design Guidelines by the applicant. It shall be transmitted to the Building and Safety Department as`y9uur
correction list. Please attach additional explanations as necessary.
APPLICANT LAQUINTA PARTNERS
SITE ADDRESS 53-295 ' Eisenhower
APN 774 - 085 _ 015 BINNO.: CASE NO.: 2000-223
LEGAL: LOT 3 BLOCK 210 UNIT
CHECKED BY: Leslie Mouriquand
S.C.@V.L.Q.
DATE: , 5::—/ 7 O
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
Compatibility Review
Case logged and number assigned
Verify legal and APN information
Consistent with MDG on file (as applicable
✓.
MDG filing required (5 filings since 9/3/98)
Consistency with street/surrounding area:
p By COMMUNITY KNELOPMENT DEPT Colors Materials
Architecture
Other Requirements:
vo
GTL
N
4
ffCertifica'te 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:
Occupancy Group:
SFD
53-295 EISENHOWER DRIVE
R 3 Type of Construction:
Bldg. Permit No.: 0004-212
VN Land Use Zone: RC
Owner of Building: LA QUINTA PARTNERS Address: P.O. BOX 134
City: LA QUINTA, CA 92253
�. By: STEVE TRAM
Building Official
Date:. 09-01-00
POST IN A CONSPICUOUS PLACE