9805-042 (SFD)LICENSED CONTRACTOR DECLARATION'`
Ihereby 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
<Frofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
3 i iQ
,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: j
()(�() I, as owner of the property, or my employees with wages a5 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).
(kI am ex 'mERKER'S
ection B&P.C. fovt is reason
Date
Signature of Owner
COMPENSATION DECLARATION
I hereby affirm under penalty., of • perjury one • of the following declarations:
( ) A 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
Sa.tion .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.
x E.11CK I NSti1;.ANCE i A200 4370 (10 ?65
(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. sons of Section 3700 of the Labor
Code, I shall fo hwith comply with thos pro •stuns.
ate:_5APPlicanf
Warning:, Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propert2for', ection purposes.
Signature (Owner/Agent)-_ Date
BUILDING PERMIT PERMIT # °°NTROL#'
�3:14305..11�.'L i''����ppp .
DATE
/ /� VALUATION 577.40.70 LOT TRACT 77 3 8
r
JOB SITE I 54-MiA1rENk.lirEtRr9AH11li.Z
APN 773,465.0.0
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
�ARfIlil:.. X31 r1;101,,!
0WNE' ! Rtt11• DEft. w1"1`1-1 M. (C"
110 BOX. 663
45701 [VIGItN) RIDE 9111.;M,' G
CIDACHV,,LLA CA 92216
(( INO CA 92201
(701347.3j 57 ("BL#
}
USE OF PERMIT
Sh0
9 k
Sl: D - (3.B MROON1 a 111 I• DORS NOT INCLUDE' L�1.U+w'fC ViAL1 S ok
(%(.3iX.
TTi�^ CT CORTIR.UM10IN 1. �is.;,f� &,-. I'fl
Y 1 1°�8
K5Ii NIRA JO 1(Y2,(itf Sr'
VARA.CJR/CiUZPOlt F 526.(w 8F.� iT
g` Ll�� ( ' 9 � ! e
.4i..S'r I:1!IA f.1~ D COST OF COIR�1` I l iL'�':t.;r1Y
77,640.70
nnp �pp� y,y,,yA9
1eJ &�di.: F`� 1:;Qri.F✓ c�X�IY.dJ\`YAA Y
C,ON'StTRUcTION 1-:E 1017(W-418,000 i540_401
F+1, AN (71-TrY,F EE 1$�1.11f
`fECHAN1.CAL FEE 101-000-121-000. V0.56
filDCT1t1CAL FM "101 -000 -j120 -M $1 t6.55
P1.1)MHIN T r'f-E ;01-000.411'-000 121. 50
S't RC)tifO NJ0°( K)N FFR - P-178fT) 101-000-241-000 $7,70
GRADING I• J1 101 -000 -423 -MO B2n.00
1N.f;R/kS` RU(`. i%i ,ft FEE 22.5-(M-443-342 Sd,71fi.3,S+
t>#iF.0"iSE PLAN 101 -000 -WW1 -345 $+2.4.00
SUB-TOTM, CONS'1'IttX-MON A 14D PY.,.R N CH RX
9,04.4,30
LESS PIU -PAM FEES
$0.00
TOTAL ii'11MM)'117 FE ES 131JF NOW
53,044.319
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 a-
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
S 8
Final
Final
POOLS -SPAS
BLOCKWALL APIIROVALS
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 LinesHeater
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 ice% f:,o
Appliances -'—!
Final
COMMENTS:
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 CC
Utility Notice (Perm)
Notiee:
Document Cannot Be Duplicated
Desert Sands -Unified ,School District
82 879.'Highway •111
Indio, GA 92201
619.475-3500
CERTIFICATE OF "COMPLIANCE
Date 5/13/98 APN # 773-165-019
No. 17018 Jurisdiction LaQuinta
Owner NameDaniel Mendoza Permit #
No. 51-885 Street ,Avenida Ramirez Log #
City La Quinta Zip . 92253 Study Area
Tract # Lot # Square Footage 1,215
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 cddi 53080 in the amount of
1.93 X 1,215 or $ 2,344.95' the propertylisied above and that building
permits and/or Certificates of Occupancy for this, quare footage in this proposedproject may noiA% be- issued
Fees Paid By Cashier Check/Bank of America/Bill S.tandefer Te ephane " 47-3 f 5:7
Name -on the check
;.
By Dr. Doris Wilson
Superintendent
.Fee collected /exempted by Juanita Green Payment Received $2,344.95
Check No. 2009914079
Signature
NOTICE: Pur§uani of Ass Ably Bill 3061 (6HAPj549 STATS. 1996) This will serve to notify you that 90 -day approval, period in which you may protest the fees or other payment identified
above will begin to ruri frorti the date on which the budding or installationpermit for this piojectis sssue l or on which lhey.are paid to thebistrict(s) or to another public entity authorized to
collect them on the District('s)(s') behalf, whicheve'ris 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- Accounimr g
I
Coachella Valley.Housing Coa11t1on
Plaza I, 45-701 Monroe Street, Suite G., Indio; CA 92201
TEL: (760) 347-31$7 FAX: (760) 342-6466
ATTORNEY-IN-FACT AGREEMENT
IMe 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 7 OF BLOCK 58 OF UNIT 5. OF SANTA CARMELITA AT VALE LA
QUINTA; AS SHOWN BY`MAP: RECORDED .I N. BOOK 18, PAGE 63 OF
MAPS, RIVERSIDE; COUNTY RECORDS.
4�/� ''
Date
�- 1� .
Date
f:\sfamily\an na\miscfor\attnyfa.
1
Daniel Mendoza
Eduvl�es Velazques Mendoza
C- -(7�7,7-,J7-�ZT Ply", 1— TT.
"? — J77 ,
lj�
I
4
and Cocoon
7 iF, GreenStone
r;- GreenStone, a Louisiana-Paci:
X-' GreenStone Industries, Inc.
Printed in USA. RV 30M 8197.
8-97-TT/G-A