9709-120 (SFD)U)
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' LICENSED CONTRACTOR DECLARATION
%1 hereby,dffirm under penalty of perjury that I am licensed under provisions of
wClapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
M License # Lic. Class Exp. Date
CVHI..C: II 3V!Y7
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 licensed
contractors to construct the project (Sec. 7044, Business & Professionals
ode).
O I am,�exempt under Section , B&P C. for -this reason
Date ` %//J ; �'' 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.
( I have and will maintain workers' compensation insurance, as required by
S ctlon 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.
TRUCK .1 N:.+uTFar"aiit".�.1' i A:," 7 4270 00 J�
(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
Ubject to the workers' compensation provisions of Section 3700 of the Labor
Code,,kshall forthwith comply with those•provisions.
Applicant r/�
Warning: Failure to secure Workers' Compensation 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
co ruction, and hereby authorize representatives of this City to enter upon
above-mentioned property for inspection purposes.
(Owner/Agent) ►' -•-� �� Date'= -le-
?7-
V4,gnature
BUILDING PERMIT PERMIT# CONTROL#
�'7?>�s..'9.�i! 4
DATE VALUATION. S�l7,369.20 LOT 20 TRACT BR_ �i.
JOBSITEF k-i�l�li1� 1��'lSlroj�lk�t� )��8.�:�.
APN 773- '1 -WI%
..
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
7 �Airr"t
r�e A
33451)111,11": jC S-, i f k"t
H.;' N KU t.til Z5.1 IG %;
C„'l)ti(.'b11'1.1.,t1 (.'A 9'?73o
Chd[NO 02"."01
1760'1.1.41- 3157 CW, it
-
USE OF PERMIT
5 I�
3.E.D. i>a.:k MI i i;!tiES N0T I CILLAA a3LOCK WALLS OR P00L. P1. INN
r:m, '1C. i1oft.11cm, of F.7'e' BZL'X>i CEO 7:9>1; FoR. tLtl tl:,`1`i!fu f°w '
SAME FALAN TVPF.
P0110PPA`iTO h'.1.00 Sr
UARAGSIC; ARPt)R7 526.00 SF
it. i d>► M a �iw i4 C�� o Ulf:
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings a
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap Fj
F.A.U.
Framing
Compressor
Insulation ,W,iz
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 APPROVA S
POOLS -SPAS
Steel:
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping
PLUMBING APPR VALS
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 / L
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 44444P -,F4
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District
Notice:
82-8'70 Highway `111
Document Cannot Be Duplicated ' Indio;•CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
Date 9/26/97
No. 16122 Jurisdiction
Owner Name Coachella Valley Housing' Coalition
No. 51840 Street Avenida Ramirez
City La Quinta zip' 92253
APN# 773-171-005
La;.Quinta
Permit #
Log #
Study Area
Tract # Lot # 20 Square,Footage 1210
Type of Development Single, Family Residence-, No. of Units 1
Comments
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
1.84 X 1,210 or $ 2,226.40 the property listed above and xhat building
permits and/or Certificates of Occupancy for this square footage in this proposed proje f mays now be issued
Fees Paid By oc/Bank of America/CV Housing Coalition ''Telephone 347-3157
Name on the check..
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Pauline Pearson Payment Received $2,226.40
Check No. 260671-1031
Signature
40T CE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90<lay approval, period in which you may protest the fees or other payment identified
above will begin to run from the dale 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
tilled 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
Coachella Valley Housing Coalition
Plaza 1, 45-701 Monroe Street, Suite G., Indio, CA 92201
TEL: (760) 347-3157 FAX: (760) 342-6466
ATTORNEY-IN-FACT AGREEMENT
I/We hereby appoint COACHELLA VALLEY HOUSING COALITION,
and/or any of its authorized agents as my/our attorney -in fact for the
purpose of executing any notices of completion, waiver, of liens
and/or executing contracts with subcontractors, and/or release of
liens and/or handling building permits relating to that certain real
property described below.
All that certain land located and being in the County of Riverside,
State of California, described as follows:
LOT 20 BLOCK 59 OF UNIT 5 OF SANTA CARMELITA AT VALE LA
QUINTA, AS SHOWN BY MAP RECORDED IN BOOK 18, PAGE 63 OF
MAPS, RIVERSIDE COUNTY RECORDS.
1__,
oZ -n'y &e be dc_ Oco o
Date Enrique Escobedo Bello
T.H.IS ATTIC HAS BEEN INSULATED TO:
RESIDENCE ADDRESS:L---�y1
aAve. .r
La- Qriir4r�, rig
INSTALLED BY:
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This attic has been insulated to the It -value CERTIFICATION:
indicated above, with Cocoon" the high•cfficicncy This is to certify that attic insulation, has been installed
insulation. Made from a minimum of 801' recycled
materials, Cocoon is scientifically formulated-- in conformance with the coverage chart recommends -
to deliver greater efficiency per inch than other tions on the opposite side of this card using ags
insulation materials. -.
to cover% d sq. ft. to obtain an R -value of–.�
R -value is a measure of resistance to heat flow — the
higher the 11 -value, the greater the insulating power.
If you would like to add more insulation to your LjAL�WS AUTH.O,RIZED SIGNATURE ,DATE
home, contact your Cocoon authorized dealer.
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