9709-116 (SFD)P LICENSED CONTRACTOR DECLARATION
-1 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
CMAc 12/3114117
Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
icense Law for the following reason:
S I, as owner of the property, or my employees with wages as their sole
/compensation, will do the work, aria 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
Cod'e). ter,?
(/S I am�e empt;under ection B&P:C�rfor th's•reason�'
'1Date�' ;"'PP:7 Signature of Owner"`' rf/"
r-
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
pert rmance 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 "1iC"K' 1N5„2A%Co .3 ' Policy No. 1ndt'n? 4370 00 ?.r,
(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
Code, I shall forthwith comply with - ose rovisl qs!
Date: •' / �� ApplTicantY
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 4 X hereby authorize representatives of this City to enter upon
the'above-mentioned propertyrfo� inspection purposes. �,!
/Signature (Owner,Agent).--- Date
PERMIT# CONTROL#
BUILDING PERMIT5977
DATE f VALUATION_ �"j��j� 1�j LOT TRACT
JOB SITE�.1+'�t i'1'�} �A6�` :�.t.NI DA VALI t 0
ADDRESS
APN 773-172-005
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
414745 INJOIVK.OF &C #9
4.1`01 i�'[ON1 OfJ Kr SM,- bs
INDIO CA 92201
WOW') CA 922101
(70 )_-447-31 17
USE OF PERMIT
;FD- K -f WT DOES NCR b .IN,_`L(D BLOCK ili;iu s OR i?tc"ic
IRA,'�T C0W,`URJJCT1_'0N 3-2101-00 114.1
PGRC-11/'17M10 to2.00 sr.,
GAfL!§-O&Cr11<1'cjlt17 S:fC.{+ I
.VIAS II NIAT-4il) elf.3 Y O'..? i;`i�.sNv",31�. s...��.;,a.��.}IN
.7„i.1s'�:s�°i..
'� �i /��",7' .1 g `� � q j
i4c. 1��N.I FEE M' l.1tQi.I�fl�\,RY
?..;A�f CiiF,?;? 1,01 -M -439-31f },q.t: it5
MCI IANICAL .HT1.: 1,014.04w41�000 Vt SO
M.L•C<' (CAILFEE. i)f- 01t1)-420`-0CA) w1,16.3T
PLUMMI11G RE 1.014)09 -4.14 -WO
0•1r,c.rcya't{�?H1.1?yi:i� tnt,()t�1-Zai-tldx>^ :d
�: .� 1t u °t 1;€? 1.I? ►-G otb a42�! 40 20.00
N1--RA8':ikiii'(:'Uiai:rrA-: 22S-000443-342 S.1,710,118
!�'Ttvl:erl9t/, �I.A�d 1.�;f,-t30S)-ofd 1-�4:'► �2� ia1
I,% .C'."•ric
10,,£1 t 3
TOTMI HI1dM T l 4 01.1 NOW
$3.0X1,94
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
J
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
of
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
tI
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -.Int. Lath
Y
Final
Final d
BLOCKWALL APPROV S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
j
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral141,
44 92
1v
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Utility Notice (Perm)
COMMENTS:
Desert Sands Unified School District'
Notice: 82-879 Highway 111
Indio, CA 92261
Document Cannot Be Duplicated. 619-775-3500
' e
CERTIFICATE OF COMPLIANCE
Date 9/26/97 APN # 773-172-005-
No.
73-172-005-No. 16118 Jurisdiction - La Quinta
Owner Name Coachella Valley Housing Coalition Permit #
No, 51850 Street Avenida Valley Log #
City La Quinta zip 92253 Study Areae
Tract # Lot # 20 Square Footage 1210
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 ,
1.84 X 1,210 or $ 2,226.40 'the property listed above and that building,
` • —� .mai {
permits and/or Certificates of Occupancy for this square footage in this proposed project m"ay-now:be,issued
Fees Paid By oc/Bank of America/CV Housing Coalition 'qelephone ;047-3 1. R
Name on the checkA,
Z
By. Dr. Doris. Wilson''
Superintendent'. , K.
Fee collected /exempted byPauline Pearson Payment Received 12;226.40
Check No. 2006711031 `.
Signature (0011. ,t
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90-6y approval period in which you may protest the fees or other payment identified'
dove will begin to run from the date on which the building of installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity, authorized to
)Ilect 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 -
• • 4
.. -
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 ,
1.84 X 1,210 or $ 2,226.40 'the property listed above and that building,
` • —� .mai {
permits and/or Certificates of Occupancy for this square footage in this proposed project m"ay-now:be,issued
Fees Paid By oc/Bank of America/CV Housing Coalition 'qelephone ;047-3 1. R
Name on the checkA,
Z
By. Dr. Doris. Wilson''
Superintendent'. , K.
Fee collected /exempted byPauline Pearson Payment Received 12;226.40
Check No. 2006711031 `.
Signature (0011. ,t
OTICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90-6y approval period in which you may protest the fees or other payment identified'
dove will begin to run from the date on which the building of installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity, authorized to
)Ilect 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 '
Map 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;" y
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 20 BLOCK 60 OF UNIT 5 OF SANTA CARMELITA'AT VALE LA " r
QUINTA, AS SHOWN I BY MAP RECORDED IN BOOK 18, PAGE 63'OF
MAPS, RIVERSIDE COUNTY RECORDS.
Date Rigoberto Morales Ramirez
Date melda Rocio acias Ramirez
�+ Vit. vo-';! ; ; •.t .� .'y-.1' ;+• :,� 1 .. 4' : f-�' ` �`S✓ ea<tft {i:.�! : G
RESIDENCE ADORE
El . �..`iFL I
.:
THIS ATTIC HAS BEEN INSULATED T 0
ily-
CERTIFICATI
:ly,t'• i';! f:,.. •G':. �'r FYI C: , a : {i 1insulation materials.
i :D
This attic has been insulated to the It -value
indicated above, with Cocoon-, the high-efficicricy This is to ccrti�, that attic insulation has been installed
i. Made front a rnininium of 80% recycled
in conformance with thc coverage chart rccommenda-
j t ials, Cocoon is scientifically formulated
to deliver greater cf0cicncy per inch thin other tions oil the opposite side of this card
l �IF fi.
7 t
higher the R-v-.tluc, the greater the insulating
-`''•'*"� : _ : ^.��`,.✓r fit. �t •d � fi .'r:,� power. �1�9, ' � � � '�•��
If you would like to add more insulation to your
(INSTAIAR'S AUTHORIZED SIGNATURE. IATE
horne, contact your Cocoon authorized dealer.
- �.'"'_ _car yam— _ -so.r� •c'
. :4
777T..
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(.'(x:(()n ticithiliZCd 1IISUIatiOIl
30 Ih. has.;
ATOMIZED PNEUMATIC APPLICATION
COVERAGE CHART
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10.8
25.6
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26.9
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102.8
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30.6_
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6iran nStnne Indusisies, Inc. All n8h1s mserved.
27.7
•�•`
Printed in USA. NV 30M 8/97.
Sldewalls (pressure
titled-densily
2.0 PPCF)
8.97-TT/6•A
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