9807-197 (SFD)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 # Lie. Class `Exp. Date
C V'14C 12/31198
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: •1
( ).. 1, 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).: t
(�.) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). '
O I am,�gxem t -un. er Section B&P.C. oG his eason
eDate k� G "Ct . Signature of Owner A-4;
f WORKER'S COMPENSATION DECLARATION
F •
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, fof the
performance of the work for which this permit is issued. N
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:
Carter Policy No.
TRUCK tNSLf4tANCE 1 A2007 4370 (W 96
(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 1•should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sh II fo hwith comply with th se provisi .ns. ....
,'Date: Applicant 's '
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'Secfion 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 f9elpsEpection purposes.
/Signature (Owner/Agent) Date .
PERMIT # 4 CONTROL #
BUILDINGPERMIT
DATE VALUATION LOT TRACT; it
JOB SITE
ADDRESS 51-380 AV�.tNIDA•�'.CL. ,SCO
APN
'T73- 07'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ACACK"S„�;
OV-TNER ! 1?1.,T1LDER �'�'!"F :=1 �;�iC
Va WX 167
4371/1 MONROE ST STF G
3:1-IERNIAL, CA 92274
IN DIO -CA 92201
f-760)347.3157 C81116
,
USE OF PERMIT
SINGLE, FAMILY L1W111,L1NtJ
.. ' .
SR)-1�.1�i11iiT '00B8 NOT/ INCLUDE BLOCK IWALL OR:F061.15%-Kfi"
An.
C Ht:(K.tdt;J7 X! 1G,N AIA;I EOi 6
#
,
�.ri U-0--tc.
TRACT COI ISMUCTION 1,21 Sr t
..iTY OF I
A. QUINIrA
.
GA1tAG1lVCA1:cP0Wf . Y26.00 $F,.
1
Eyy COS CDON@ARInryN
E.STIVIA
77, 640.70
.7nESTIVa
PE141%flT ME SUMMARY
CONS`t'RiJCTfIGN FEE 101-0X)(18-00 i $SA0.5ti
`
F1,i,fNN CM. 101-000-4-19,318 $114.03
Pe1SCHANICA1, FPW 101-1WO-121-000 U0..50
.'%Cry°B21uAt; r'E' 101-"1-420-00o 4116.35
PPA M131'NO FF.9 it11-1 QJ.9«1 f30 $121.50
S'3'1itDNO Nf(YT-10N FL'e; - RESID . 101-OW241-01A 41-+ $7.76
GRADING FEE 101-000-0,3x000 $20.00
INFRAS'1RVC'1`17KE Fff, 225-000-443-347, $.1,716:39
PF;ECISS PLAN 101-000441-345 S25.00
SUB-'! (T AL CON 9J T<LJC E7.O.1 AN!) PLAIN C 141ECK
$2,702.23
LESS PRPA-'AID BEES
$0-W
iaVAL:taERNIff ii+`DES DIJ9NOW
S2.702.23
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APP OVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
6
Return Air
Steel
Combustion Air
Roof Deck
— j —
Exhaust Fans
O.K. to Wrap
- - p,9
F.A.U.
Framing
_
Compressor
Insulation
Fireplace P.L.
_=
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final E `[
BLOCKWALL A P OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Waste Lines /
Gas Test
Electric Final
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
Appliances
Final
Final _
Utility Notice (Gas) (!, 7
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:
�a
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
i
Document Cannot Be Duplicated 760-771-8515.
CERTIFICATE OF COMPLIANCE
Date 7/31/98 r iAPN# 773-091-007
No. 17428 Jurisdiction La Quinta
Owner NameCoachella Valley Housing Coalition Permit #
No. 51-380 Street Avenida Velasco Log #
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage 1,215
` Type of Development 'Single 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
1.93 X 1,215 or $ "2,344.95 the property listed above and-thattb"u dhi"V�'%t
permits and/or Certificates of Occupancy for this square footage in this proposed projeffniay.,nov be issued yZ''1
r
Fees Paid By CC/Bank of America/David Brudvikiepi►one34,7*'157�
,�.
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,344.95
Check No. 2009916227
Signature
F
CE: Pursuant of sembly 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
will begin to run rom the date on which the building or installation permit for this project is sssued or on which they are paid to the Districts) or to another public entity authorized to
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.
r ,
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
' G
Coachella Valley Housing Coalition i
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:
(PLEASE SEE ATTACHED -"EXHIBIT APT
Date Acacio Soto
r
fAsfamily\an n a\m iscfor\attnyfa
13
Sincerel ,
De is
S. Wish PE
Structural Engineering Consultant f rOFESS/pN
`� DE 'Nis S. WISH 2
C7 N0. C-1`141250
w
CC p, p�
?NIL 7
CA'1
' STRUCTURAL ENGINEERING FOR • CUSTOM HOMES • REMODEL • COMMERCIAL • LIGHT INDUSTRIAL'- SEISMIC RETROFIT & REPAIR • UNREINFORCED MASONRY • RETAINING WALLS & FOUNDATION • REPORTS:
DAMAGE ASSESSMENT • NEW ROOF • INSURANCE CLAIM • DENNIS S. WISH P.E. HAS BEEN A MEMBER OF THE STRUCTURAL ENGINEERS ASSOCIATON OF SOUTHERN CALIFORNIA SINCE 1983