9811-111 (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 Al Lic. Class Exp. Date
/te_j//'
. 1 i�� iJ &.31aW1
ip / —/',""Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's i
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 t9 -,property, am exclusively contracting with licensed
contractors to construtothe 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 p6nalty of perjury one of the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provii ed 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
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.
> 111h "111
1M
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(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
Codyl`'shall forthwith comply with those provisions.
l te: f — Applicant
�..Y. .E -
Warning: Failure to secure Workers' CompensationpCoverage 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 property for inspection purposes.
~! ( r:
Signature (Owner/Agent).�� sy .- _ �'' �• Date—//
BUILDING PERMIT PERMIT#
DATE VALUATION LOT q TRACT
JOB SITE S S A �t
ADDRESS 52-200 <�VENIDA Iv4PTA MSCO
APN
i 7.10-212:i �)i11
OWNER
CONTRACTOR / DESIGNER / ENGINEER
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USE OF PERMIT
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RECEIPT
DATE
BY h
DATE FINALED
INSPECTOR
-;a
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
ar
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Y
Compressor
Insulation
r� . E Q
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
POOLS - SPAS
BLOCKWALL
(,APPROVALS
steel
Set Backs
Electric Bond
Footings
—/—
Main Drain
Bond Beam
— —Q �j �,
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
Pool Cover .
Sewer Connection
—
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) -C
ELECTRICAL APPROVALS
71
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) Z
}
Desert Sands Unified School District si
47-950 Dune Palms Road
Notice: La Quinta, CA 92253 '
Document Cannot Be Duplicated 760-771-8515'.
CERTIFICATE OF COMPLIANCE
Date 1/14/99 APN # 773-225-011
No. 18240
Jurisdiction La Quinta
Owner NameMichelle Erchstedt Permit #
No, 52-200 Street Avenida Velasco Log #
City La Quinta Zip 92253 Study Area '
Tract # Lot # Square Footage 1470
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 the amount of
1.93 X 1,470 or $ 2;837.10 the property listed above 2rid'that build ng
permits and/or Certificates of Occupancy' for this square footage in this proposed proje t' may no bei sued
Fees Paid By CC/Valley Independent Bank/William Thomas' Telephone "' 564 8470_
Name on the check ''r-�5�� "" • �` .
r ,•
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $2,837.10
Check No. 183020
Signature
NOTICE: Pursuant of P#embly 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 om 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
collect 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
RECORDING REQUESTED BY:
CHICAGO TITLE COMPANY COMPANY-
98.8029KC 87009955
WHEN RECORDED MAIL- THIS.DEED AND,
UNLESS OTHERWISE SHOWN BLOW,
MAIL TAX STATEMENTS TO:
THOMAS BUFFIN
C/O Power Brokers
50949 Washington Ste 1—E
GRANT DEED
I FOR RECORDER'S U
APH: 773-225-011
The undersigned grantor(s) declare(s):
Documentary transfer tax is $.00
(XXX) Computed on full value of property conveyed, or
(...) Computed on full value less liens and encumbrances remaining at time of sale.
( ) Unincorporated area: ( ) City of ,,and
FOR A VALUABLE CONSIDERATION,,receipt of'which is hereby acknowledged,
MICHELLE EICHSTEDT, AN UNMARRIED WOMAN
hereby GRANT(S) to
THOMAS BUFFIN, AN UNMARRIED MAN
the real property,in the City of LA QUINTA, County of Riverside, State of California,
described as:
LOT X11, BLOCK 74 OF SANTA CARMELITA AT VALE LA QUINTA, UNIT 25, AS PER MAP
RECORDED IN BOOK 18, PAGE 70, RECORDS -OF RIVERSIDE COUNTY, CALIFORNIA .
Dated November 24, 1998
State of California
County of Riverside S.S.
On November 24,-1998.
before me, Kelly Collier
personally appeared
Michelle Eichstedt
personally known to me (or proved to me on
the basis of satisfactory evidence) to be
the person(s) whose name(s) is/are subscribed
to the within instrument and acknowledged,to
me that he/she/they, executed the same in
his/her/their authorized capacity(ies), and
that by his/her/their signature(s) on the
instrument the person(s), or the entity upon.
behalf of which -tie person(s) acted, executed
the instrument. 1 �'
WITNESS.Ty ha d
Signature
MAIL TAX STAT NT
n'
fici seal.
THOMAS SUFFIX
SAME AS . ABOVE
l
t
R
c
ICHELLE EICHSTEDT
�.�•',. KELIY
COIUER
([ Comrn, q 1057217
r � voTPJtY PuauC CAlF0fiN1�
• �� Riveride Count
My Conan , fxpims May 28,1999
(This area for official notarial seal)