9807-108 (SFD)LICENSED CONTRACTOR DECLARATION PERMIT#
$i Iereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT�'�i-11i
Professionals Code, and my License is in full force and effect. "lei Y;itZ.946 � 23
License # Lic. Class Exp. Date
C UHC
JOB SITE q
iZ31,iQ ADDRESS -51-� 90 AI EiNWA HE"ERA
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). t
( ) I' am xempt under Section. B&P.C. f r is reason
ate - Signature of Owner -
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.
i'.liUCK ii>iwiiR!`IVll ;1 x12007 4370 C0 6
(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 personin 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
YC de, I s all forthwith comply with th se visions.
. Applicant �� •�� .••-
Warni g: Fal 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
the above-mentioned property f r inspection purposes.
/ignature (Owner/Agent) Dat
OWNER
53429 LA PAG
& A.C.HELLA, CA. 92236
USE OF PERMIT
r
X
TRACT 1161,1.15
APN
??X173-602
CONTRACTOR/DESIGNER/ENGINEER
45- 70 1 INIONROF, ST 91P G
?NDf.0 CA. 9"201
(7(10)347-31 57 C BI,.#
"14) - PLAN iYJr2b PMRA41'1 DORS NOT INCLUM. d1:C(,.K WALLS OR
�'r�K)L. PLAN „HECK I�I:iE REMAUC EID 7W°'Si�OR MUL"l IPLL: i3:iDANCE Or. ;
SAME PLAN'TWE,
'E`1cA.CT Ct;.fv:�ii"13.iFC, 1'1014 t,�tt2.00 S1
PMC I WPA C10 I ti9.00 Sly
:MATED MS's` Off CO1`dS'r!'RUC""1ION
PORMd"l ACA 81) N4 NIARAr
� ,'tafVS`1.7tE1C"i'I�?iJ F03,
ioi-01041.8-000
$563.00
NjAiN0-MC K OFF
I0t -IM-439-31f3
pffl,-3
N1.11 I11WICAL PEE -
lot -000-471-900
.D LC G'lRW/#.L I`U31
'101-000-420-000
1''{ lffylH1N(1 SER
10i•d)W-419-900
s`!'uONO f ty>�EONWr fat;S(E'r
10e.000-243-000
CRAVING ITT
101-000-423-000
..1Nt RA.379'Rt10°1JRA3 F01
225-000_443-:342.
P RFCIS.E PLAN
101-000-441,-N.
�`d4.Ctit
PT
STJC1.1rrrAl.. t'Csr7S1'itI1C;1'1CiN ANi? 1'�A�1 C"i ii•C:
LESS t'U PAID FEES
S
TOTAL JIFRM IT Ff' WN 011 E NOW
BY 6 1. 1 DATE FINALED I INSPECTOR
w,.
x,834 65
$0.00
4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL. APPROVALS
Set Backs
Underground Ducts
Forms & Footings4 r: R74 Rs- ZZ
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Dock Q
Exhaust Fans
0. K to Wrap 4:
F.A.U.
Framing V.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath _T
Mv.
Final
Final Q
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam S.
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
Equipment1n-closure
Shower Pans
0. K. for Finish Plaster
Sewer Lateral 0 1�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test 57
Appliances -
-----
Final
Final
Utility Notice (Gas) LT -7
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
:G.F.l.
,.'Smoke Detectors
: Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
-
T4tyl
" �`
P.O. BOX 1504 APPLICATION ONLY
Building -495 CA LE TAMPICO
Address �� ! / 1 V� INTA, CALIFORNIA 92253
Owner
O A 16-f /it-t-,o1/ii
53 / BUILDING: TYP�ECONST. 1-7
OCC. GRP.
Mailing
Address �'pl �q it-of%��`� A.P. Number / 7 -73 `}' r—%3
City Zip Tel.
elaftl4p
Contractor
Address
Tel.
State Lic.I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City IZip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to 'Its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I- 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. It, however, the building
or improvement is sold within one year of Completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose Waste.)
I'l 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
i 7 1 am exempt under Sec. B & P.C. for this reason
,
I.
r
Date �/a- /T
_wner J' %�Ae— CXV
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. ❑ certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit Is for one hundred dollars ($100) valuation
or less.) r
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.
Date Owner
NOTICE TO APPLICANT. If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above.
mentioned property for inspection purposes.
=� Signature of
Mailing Add
City, State,
Description / •�/� ,,,
;t Description45'�h.G/ LF Y%,f
ce
Sq. Ft. No. J No. DIN.
Size / �2 . Stories ! Units
New Add D Alter ❑ Repair 0 Demolition ❑
Estimated Valuation
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOT
REMARKS
AMOUNT
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
Coachella Valley Housing Coalition i
Plaza 1, 4S-701 Monroe Street, Suite G., Indio, CA 92201 —
TEL: (760) 347-31 S7 FAX: (760) 342-6466
ATTORNEY-IN-FACT AGREEMENT
IMe 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 A")
�G /,T –7F
Date
f: \sfa m i ly\a n n a\m is cfo r\attn yfa
ti
k/
Hector Aquino Aguillon
Notice:
Document Cannot Be Duplicated
Date 7/28/98
No. 17405
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Owner NameCoachella Valley Housing Coalition
No, 51-780
City La Quinta
Tract #
Street Avenida Herrera
Lot #
Type of Development Single Family Residence
Comments
APN # 773-173-002
Jurisdiction La Quinta
Permit #9807-108
Log #
Zip 92253 Study Area
Square Footage 1,302
No. of Units 1
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 Jr, the•'ambunt of
1.93 X 1,302 or $ 2,512.86 the property listed above and -that building `% f'
permits and/or Certificates of Occupancy for this square footage in this proposed project'may now be issued'
Fees Paid By CC/Bank of America/David Brudvik A , �.
q'elzphone�:; '
�' -
Name on the check -�
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green
Signature
Payment Received $2,512.86
Check No. 5404 aoo9 9 ((e I (,, 3
INOTICE: Pursuant of Asspbly 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 from 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.
d 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