0211-192 (CSCS)78015 Main St
0211-192
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
Ate ' Signature of Contractor LA
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 (Seca 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 am exempt under Section B&P.C. for this reason
Date Signature of Owner
1
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.
(-tJ 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 STWJF, F1JjIO Policy No. .1449125-0.2
(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 those provisions.
Date:? ✓ ll Applicant % • k -- -
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. I
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 forinspectionpurposes.
VSlgnature (Owner/Agent) ,r7:yJJL.n ! . Date 2,111-16
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BUILDING PERMIT PERMIT#
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DATE 1 VALUATION q v g LOT TRACT
JOB SITd
ADDRESS ,L 4dCIi a 6J FFi1n'14sTr a ronA C
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OWNER
CONTRACTOR/DESIGNER/EN (NEER
78-081D, CATTZX. `CAD0 M? 2011,
'( 8.013 Cxwk'y fiA. '.2 M.400372 203
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LA 92253
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CA
(760771.2567 CV -4i 5407
USE OF PERMIT f
C01000:1 R Al:
OLD TOWN' LA QL'"f.N TA (f3WO A) .. fifes CaCC.,TYPE? V -'N (NO SINAL
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.ADTUST'k4 ? .T 1' 1.4C5.. LGlLEZ)
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AIC -• COMMERCIAL Srf
CONTRACT OUNT 1,=,353.30 L
MIRMTfif61! 8(MIMA2' Y
CONSTRUMkOA3FEE 101-000-418-000 $4;0".50
PI -04 C,191rcKis 101-000-439--3113 0,529,13
'FIRE DEPOSIT 101.000.439-M 41,100,00
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1011-t6p00- ft +2q,71 -i OC) $5p96. 50
gib 4ppEi,HA T,'IC1:;.}AL,,.'ap ':[r. .
3LUt 4., InMF 101 ` i40-4 A.\bY000 8 i1c 196
k'k,lBfiRzBIND FEE 101-000-41.9-000 $301.50
3TIiOW MOTION FRE - 6:OjER IM IC1O.000.2=41 -300 $23a.'sd
15.V F3,011YA.ifiIAAS'.': FFB 93 ,09 .99
;AU IN PUNA(! PLACES - W:hff 370.000.445-000 %6,170,44
e l 0.9 A'h'PD ;t.S,.AbT CIMMC
$6% 4.20
c, i. M8113 PAW -15 I S
_ 1.1500.00
FEB 2 6 a:Mml FXVIS DDR, NOW
CITY OF LA QUINTA f
FINANCE DEPT. t
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RECEIPT
DATE
By `
DAT INAL
/
INSP
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
Framing
( a t ,Q
_ Q y `
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
lQ" Uy
Final
//
Final ( _
BLOCKWALL APPROVALS
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
_
Heater Final
Plumbing Final
Water Piping
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:
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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) l/l
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Certificate of Occupancy
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Building. & Safety Department
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This Certificate is issued pursuant to the requirements of Section 109 of the California Building
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Code, certifying that, at
the time of issuance, this structure was in compliance with, the
provisions of the Building Code and the various ordinances of the City regulating building
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construction and/or use.
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BUILDING ADDRESS: 78-015 MAIN STREET
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Use classification: COMMERCIAL Building Permit No.: 0211-192
Occupancy Group: B/M
Type of Construction: VN, SPRINKLED Land Use Zone: VC
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Owner of Building: OLD TOWN LA QUINTA, LLC Address: 78-080 CALLE ESTADO, STE. 201
City, ST, ZIP: LA QUINTA, CA 92253
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By: KIRK KIRKLAND
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Date: March 11, 2004
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wilding Official
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POST IN A CONSPICUOUS PLACE
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