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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
Date 'ar �^ rl �a 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 tlfe 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.
('x) 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 FUND Policy No. I1601"W-01
'c
(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 ageee that if I should become
subject to the workers' compensation provisions of Section�700 of the Labor
Code, I sh �I fo hwith' comply with those provisions,.;
Date: ��, j.l ji Applicant / /I/ -sem' Z
Warning: Fai ure to secure Workers'iCompensation 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 I,"
the above-mentioned property for.in'spection purposes.
Signature (Owner/Agent) f �''� Date r!' t%�
BUILDING.-PERMITPERMIT#
g
� `� �'2 -� `�
DATE VALUATION LOT TRACT
U21,02 un,361M 1•Y Br.Y.297
JOB SITE
ADDRESS 54-2J.0 . .9, EKFJ0Wr_- R DR
APN 774-22.1-033.
OWNER
CONTRACTOR / DESIGNER / EN INEER
z.LAW.Mi MrF"R.l`S1~
NiCHOLM DE 01, ARMS
R0, 111M 450
745 N5, M A R ENG 0 -
L& QURRTA CA 922$3
R&SA MA QA 91.106
(626)584-4844 (MLO 522:4
USE OF PERMIT
SLI 0U.:FAMJLY Dw1 11110
SYD - PEk'MI T.000 NOT INCLUD.11t iil.= WAIA,, POOL OR L°•,',aIVn� V.&Y'
APPROACH, 48 CODE.
TRACT C'6sRS1'1Z1.' CT100 118.16,00 3F
1=[d1:CHIP.,ATIO 41.00 Sly
("M)'AOI,!(,'AWPOR F 504,00 3F
5 FT. VdfJOD F12,9CE 760.00 Ll+'
9FID TFID C05111 QF ("ON 1110A';MIGH
117 369.50
CONSTRUCTION i &P. 101 900-419-000 $x35.00
P,L.AV CREC1: I &F,, 7.01-0(X)439 318 $566:70
FEE DEPOSIT 101!•000.439.318 4250.40
MY..,f HAN1t.:.AI, PZZ 101••000,4214;00 i66.50
ELECTRICAL&'ER 101-000.420000 $123:19
PLUMB1N131EE 1.01-€100-419-000 $116.09
STIRONO M07'.CON FEA - R.k:VID 101-000-24)-000 $11.24
GRAD1NC{ 1-?' 101. -OW -423.000 $20,01)
DEVELOPER IMPACT FEE,$1,901.019
PRFZ1SI? .PJ.A14 101"000-441-345
rt
w"it..�Li^',e(7T�'AL �wL.!J.'�Ta'f,.d3iC•isvr.�'�.L��,�.cw .t.11`!J..� m,,A.T.'�7 (.:duJ:C:t9.
+e'�y?7 f.cD.7'
�1S2 50.00
TAT.. 1'i.'!7�!1�'.1" MKS DUE NOW
3347:3
BAR 2 7 20Q?
CITYOF�AQ(HMTA
NJ
RECEIPT
DATE
r�
BY
D E FINALED �j
INSP
•
.. (.,
.2-
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
. O Z,
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
(0_014 - o?i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. o Z_-
iDrywall
Drywall- Int. Lath
O?�
Final
Final Z
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
Sewer Connection
joz
Pool Cover
Encapsulation
Gas Piping
G
_
`Gas Test _(3
Appliances
Final
COMMENTS:
t
Final , t_
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 (j
Final
Utility Notice (Perm)
Building
Address
OwnerC-��457_
Mailing
Address
Ci Zi Tel.
-&iyri9 baa-
Co tr ctor
znuU
Addre q
Ci`/T—ISGGLVA,N�q 'S� Tel
State Lic. 6 J F6�t City
8 Classif.
Lic. #
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P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
WINTA, CALIFORNIA 92253
Arch., Engr.,
Designer Ley
Address I Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that tarn 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,Susiness and Professions Code: Any city or county which requires a
permit to construct, after, 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 (E500).
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 11, 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.)
1-1 I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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. ❑ 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
Of less.)
I certify that in the performance of thg work for which this permit is issued, 1 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: It, 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 slate 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 -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant -Date-
Mailing
ateMailing Address
City, State, Zip
BUILDING: TYPE'CONLLS//T. OCC.GRP.
A.P. Number / /, �Q?7 q , _;zy
Legal Description ` oli 14 CJ�W�/�/���/
Project Description
Sq. Ft.� fj� /
Size
Stories tJ �y0 Stories
New ❑ Add ❑ Alter ❑
NO.'DW.
Units
Repair ❑ Demolition ❑
itimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
r J,
Plan Chk. Bal.
�.
Const.
i
Mech.
Electrical�-
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop.'_ine
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
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 3/12/02
No. 23 03 8
Owner NameClarke Enterprise
No. 54210 Street Eisenhower Drive
city La Quinta
Tract # BLK297
Lot # 14
Type of Development Single Family Residence
Comments
APN # 774-221-011
Jurisdiction La Quinta
Permit # 0112-13 3
Log #
Zip 92253 Study Area
ew Single Family Residence of 1846 sq. ft.
Square Footage 1846
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
2.14 X 1,846 or $ 3,950.44 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 Union Bank - Harlin Borcherding
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Crystal Scott
Signature
Payment Received
Check No
Telephone
$7,188.26
7850856
JOTICE: Pursuant to Assembly Bill 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
:ollect 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
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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 CLARKE ENTERPRISE/LENDEL VENTTTRES P INC
SITE ADDRESS 54-210 Eisenhower
APN 774 - 221 - r) ; i I CASE NO.: 596
LEGAL: LOT 14
BLOCK 21-7,9-�" UNIT ofl Z-:�" S.C.@V.L.Q. -
CHECK AND APPROVED BY: WALLACE NESBIT DATE: l2
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)
Architectural variety within 200 feet of
the surrounding area:
Colors
Materials
Architectural design features
OAm• ents:. @
O Planning Commission
O City Council
.ACommunity Dev. Depw 44 a
irn�i'ials
Case No..�
Exhibit
- A /L "t-0
ver' -7
�'�`7 P�r�rSsr�r"'
With Conditions SUL� ���-' a ST
�.rr.r"r7
1
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: 54-210 EISENHOWER DRIVE
Use Classification: SINGLE FAMILY DWELLING _ Bldg. Permit No.: 0112-133
Occupancy Group: R-3 Type of Construction: VN Land Use Zone: RC
Owner of Building: CLARKE ENTERPRISE
Building Official
Address: P.O. BOX 450
City: LA QUINTA.,..CA 92253
By: KIRK KIRKLAND
Date: FEBRUARY 24, 2003
POST IN A CONSPICUOUS PLACE