9806-172 (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 # Lic. Class Exp. Date
MI.0 IV31198
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).
(}C) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
.Code).
( )/1' am.exempt under Section B&P.C. for this reason
,Date,,6 Signatuib of Owner! Z.
y�. _ �xd
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'
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.
T01CK M9URANC1 1. ►2007 4:170 00,96
(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,
.1 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
Co6e, I shall forthwith comply with those provisions.
Date:- Applicant_ }�:. ° L,
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, intefest 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, indemnik,
& 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 v8id 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 informationis
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
thera`bove-mentioned property for inspection purposes.
,nature (Owner/Agent))""' w`<' �'�%''r Dater 'f
BUILDING PERMIT - PERMIT# CONTROL
DATE VALUATION LOT, 9806-172, •TRACT x_' '
$77;640.7015 f
JOB SITE /
APN
ADDRESS 41-440 AVEMDA VALL EJO
773-011 -®141
OWNER
CONTRACTOR/DESIGNER/ENGINEER _
fv1AR1A BLANcb
OWNER! BUI,LDER14TITEI CVHC
84904 BAGDAD BLVD
45701 IVIONROE ST S'CE G
COACHELLA CA 92236
1NDIO CA '92201
(760?347.3157 CBL'
USE OF PERMIT
M (12:1.5OR) - Pmt i' DORI'rro'r i2 rC`LUWFsLAc:k:WALLS OR POOL '
TRA(,"t- CONSTRUCTION 1;215.0£1 SF
PORCH/PATIO 102,06 `41~'
4AR.AGFJGAR.0oR`r 526.00 131 '
' 1+;.�iL[ME�D�!:DCOST Of. C()f'Yt1JCTLO
"d'7,ii4.7t1
PERMIT FEE :SIII1'[Rllc RY
CON.TMIX7'1ON FIFE '101-000-418-000 $540.50
PLAN CHECK FfM 101.000-439-118 9456.10
1WFXHAMC`,AL FES101-000421-000. $40.50
ELECTRICAL NSE °�> 101-000.4` 0-(M 1116.55
PLIJI►MINO FEE 101-fI00- 4.10.000 $1.21.50
.
STRONG MOT10�1 k EE -1ESC) 101-M-241000 - $7.76
GRADING h � `�,� 101=000423-0W sa0:co
1AIFRAS7`I2Ctti 9`t kE�; li 135-000443-342. $1,7W.39
CCI SE PLAN 101-000441-345 $25.00
A.
N9
.�+
' = CCO:NS"1'I U4'' -'CION AND PLAN CHECK
$3,044,30
LESS P:RI-PAID 1ZES
$0.00
TOTAL PERMIT !r+'.EES.. DUE NOW
$3,044.30
\t- tit
RECEIPT ��
DATE
BY /
DATE FINALED
INSPECTOR
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 4- I q-- Tal
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath —
Drywall - Int. Lath . Q
r/
Final 7�C
BLOCKWALL APPROVALS
Final
POOLS - SPAS
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 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 --a7-
Encapsulation
Gas Piping
Gas Test 6p.
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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
I
Final
Utility Notice (Perm)
COMMENTS:
..t, Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OE COMPLIANCE
Date 7/31/98 APN # 773=084-010
No. 17437 Jurisdiction La Quinta
Owner NameCoachella Valley Housing Coalition Permit #
No. 51,440 Street Avenida Vallejo;, Log #,
City La Quinta Zip 92253 Study Area
Tract # Lot # Square Footage •.1,215
• c
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 mobilehoines.
It has been determined the above-named owner is exempt from paying school fees at this time due to the following
reason:
r
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in theamountof
1.93 X 1,215 or $ 2,344.95 the property listed above and'thav`b6iJd g A Wil
permits and/or Certificates of Occupancy for this square footage in this proposed project may now„ be issued � s.
Fees Paid By CC/Bank of America/David Brudvik
TIP) }Pp h o n 347-3157 C w
Name on the check 1
By Dr. Doris Wilson
Superintendent
` Fee collected /exempted by Juanita Green Payment Received $2,344..95
Check No. 2009916225
Signature a a/)V� AZII-)
f
TICE: Pursuant of As bly 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 ident�ed
ovewill begin to runfro the date on which the building or installation permit for this project is sssued or on which they are paid to the Dislrict(s) or to another public entity authorized to
lect 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 _
TEL: (760) 347-3157. FAX: (760) 342.6466
ATTORNEY-IN-FACT AGREEMENT k.
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 15 OF BLOCK 65 OF UNIT 6 OF SANTA CARMELITA AT VALLE LA
QUINTA,- AS' SHOWN BY MAP RECORDED IN BOOK 18, PAGE 67
MAPS, RIVERSIDE COUNTY RECORDS.'_
6/nAg
Date Maria Jesus Blanco
r
r
.r
Date
f:\sfamily\anna\miscfor\attnyfa