0309-306 (RC)78015 Main St Ste 109
0309-306
LICENSED CONTRACTOR DECLARATION
I_ hereby affirm under penalty of perjury that I amlicensedunder provisions of
` pter 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,
' Date 04 Z Signature of Contractor, !- /V r r
f ✓
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).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1V ) 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 I have and will maintain workers' compensation insurance, as required by
Seaion 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:
Carver STATE FUND Policy No. 1490125-03
(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 wo ers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those rovisions. +-
Date' -ZyA Applicant g,
Warning: Failure to secure WorkersiCompensation coverage is unlawful and
shall subject an employer t6 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 oft is City to enter upon
the above-mentioned property for}nspection purposes.1
!,Signature (Owne
BUILDING PERMIT PERMIT#
DATE'• : IT VALUATION * {p X9/9 LOT TRACT
' x!
JOB SITE
ADDRESSf }i- JAI ax .JR. R
APN
h V
'
OWNER
CONTRACTOR/DESIGNER/ENGINEER
\/.4.J✓ 1•Q"" LA QW7dY A LLC
A7 AR V.I.SV H03VIES
'18.080 CAUX-1WADO RMITZ201
78.080l:1<!,Y LAMW NDO 6WY 201
:LA QLTJNT.61 CA 92253
LA QtTAM CA 92253
(7f 07714567 CTA 5407
USE OF PERMIT
C0102A1.Rtut;WFtFMC?DEL
C0M2d ERCIAI, RZ!d(YD91, (MERCANTILE SPACE TI) 2001 CKt",, 1199 S.F.
W OC4';ilP,ANCT, TYPE VX .9PRD4KLF1D, OCCUPANT LOAD 40
VAIXATION 11,990.00 1,5
E .tMYKff.D C'C3.r3.' OF, C'ON7S%`RUC.' COR
PERAOr Fa E3U.NDJA1; Y
PLKA e kIZCK FREE
CONSTRUCTI'OUFBS 1'01-0()e -G18-QOO 1 5.1j0
MECHANICAL 1?t:1k, 101.000-421.000 519.50
1P XC'i TICAL, FEF. 101-000.420-000 $20.25
SU B-TOTM,CC1NTMUM701TANDPZ-WC EC';E'. ,
;2E2.5t1
1& SS I .,1 -PKII? FEES
50100
TOTAL PERMf KKEN DAA NOW
$26:' S0
OCT 03 2003
CITY OF LA Ute wfT
/ BY Dfil FINA INSPE
V
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
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
BLOCKWALL APPROVALS
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
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:
FEB- 4-04 WED 5:29 PM RIV, CO, FIRE P.&E INDIO
Fire Chief
Proudly serving the
Unincorivratod
Areas of Riverside
County and the
'itic;, of.
Banning
Beautnottt
Calimesa
A
CanyonLake
E
Coachella
Desert Hot Springs
ri
.• ; 'n 1dc135
Indio
4
Lake Elsinore
s
La Quiraa
Moreno Valley
Palm M'W-11
G
Pcrr is
Ranohe Mirage
San Jacinto
C•
Temecula
Board or Supervisors
Bob Buster,
District 1
John Tavagliune,
District 2
J im Ven bla,
District 3
Roy W itson,
I)Lstriet 4
Marion Ashley,
I)iSLrict 5
FAX VO. 1 760 863 7072 P, i
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
10 San acro oAvenue-
February
venueems, California • ( ax ) 10 i
i
' I
February 4, 2004
City Of La Quinta
Building Department
Re: Fire and Life Safety Clearance
Old Town La Quinta.
The Riverside County Fire Department is granting a fire and life safety clearance for the
Following suites #106,109,111 located at 78015 Main st. La Quinta. Please call if you
should have any questions.
TDri
FRANK KAWASAKI
Chief Fire Department Planner
B
Y
Terry DeSoucy
Fire Systems Inspectors
c_
EMERGENCY SERVICES DIVISION • PLAD KING SECTION • 1NDIO OFFICE
82-675 Highway 111, 2n° FI., Indo, CA 92201 • (760) 863-8886 . Fax (760) 863-7072
n