9807-101 (SFD)LICENSED tONTRACTOR DECLARATION
3 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, andmy License is in full force and effect.
License # Lic. Class Exp. Date
• h
i.a't.9 it?
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: 11 1
( ) I, as owner of the property, or,!4 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). I -
( /I am exemp under Section B&P. r this reix
ate Signature of Owne at'h
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of. the following declarations:
() I have and will maintain a certificate of consnt to self -insure for. workers'
compensation, as provided for by Section 3700,6f the Labor Code, for the
performance of the work -for which this permit is issued.
()o 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 Policy No.
,Awl VtCINr SaR.r i Ano 1 10 1,70 i 9",
(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 Section 3700 of the Labor
C� cue, I sh II fo hwith comply with t e revisions.
�f5ate: Applicant
Warning: Fai ure 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
thabove-mentioned property for in pe�tion purposes.
,Signature (Owner/Agent) Date.
BUILDING PERMIT PERMIT 1f
0TRACT
DATE i VALUATION LOT TRACT
JOB SITE
APN
ADDRESS �,� �� AQ lr tVilJri YI!.ilrr4li.l#
/ 1, t 17
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LOPEZ" 1114r1)f1.i.'�1;13.f�i�'�i'.�:r.:'Y'�.
CIA -TIC
Wl 0 'v U%, ZAi i i D1
45-701. &ii: N A.0.i3.3 i' Fi 0
c'_'0AC:HFLLA. (,.A 92210
INDIO CA 92203,
001)3,17-3157 C:13d,#f
c
USE OF PERMIT
tit�1:9
. �
�:
'iES
:3113 PLAN 00201-L i'IMth•4J .i:i NOT 1NCLi OL -i 191, CK WALL` OR {
t►00J_ PLAN CI -R. <X 14r% F40) .3t EX) 7%.FOR iv.IUL a I%'LE, ISSUANCE (J+' � 1
4
3 XMF PLAN 7'M3,
g v.w• t r.+.t � N ,
CYA3f.r�(i AC t4 t:i'i;ttt't' 517.00 13F
flI'`•»jfY 4SC9XF111M S.rt IS OF tWVN.rfTi.UCTI.i7li
Vir?�ru.:�ti
HMNIff 1114,"K'SU N1 MAW
1°.*0NS11k1JC,Tf0N FHE 101«000_418_000
tN. AN I-1-jr-PU OPP R :!9
4I1(."1s`riPd;:CAL F.t t;
L-I,ts(:
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
. $
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
- 3—?q
Drywall - Int. Lath
y
Final
Final
2i
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Gas Test
Electric Final
Waste Lines
/4AL
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
ly .yp—
Encapsulation
Gas Piping
Gas Test
ST
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) Z
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
h,
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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 7/28/98 APN # 773-173-017
No. 17398 Jurisdiction La Quints
Owner NameCoachella Valley Housing Coalition Permit #9807-101
No. 517845 Street Avenida Velasco Log #
City La Quinta Zip 92253 Study Area
Tract # Lot# Square Footage 1,302
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
1.93 X 1,302 or. $ 2,512.86 the property listed above and that building,
permits and/or Certificates of Occupancy for this square footage in -this proposed project'mayAnow :be issued.
Fees Paid By 'CCBank of America/David Brudvik Tel¢pnoneu3
47-3-157 y7` 1
Name on the check
By Dr. Doris Wilson
...l 4
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,512.86
Check No. 7 -OW Q1> Ogg 1 toll03
Signature
(NOTICE: Pursuant of Asser%ily 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 fromv, 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
tolled 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 i )
Plaza 1, 45-701 Monroe Street, Suite G., Indio, CA 92201
I
TEL: (760) 347-3157 FAX: (760) 342=6466
® &OF,
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:
r
LOT 5 OF BLOCK 61 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.
Date JOSE MARIA L PEZ TIRADO
- - ---- ---- ----- L -V
------------
-DATE NGELITA RENTERIA JAU
DATE
f:\sfamily\anna\miscfor\attnyfa
---- - = —--------------
J SE M. LOIZ RENTERIA SON