0312-254 (RC)78015 Main St Ste 109
0312-254
LICENSED CONTRACTOR DECLARATION
I hereby affirm Vnoer'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
j 771883 11 11 /3 10/0.1
) f1
%Date /), d . Signature of Contractorv
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:
( ) 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 s TATE rUND. Policy No. • 144.0f25-03
(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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith, comply with those provisions.
/Date: Applicant EJa /l . % 7. --
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 hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
`Signature (Owner/Agee ) / i ;7—. Date,`y
BUILDING PERMIT PERMIT#
i. x,.-,..:
DATE „VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 76-015 MAIN F1€KWf SMrg 109
-
OWNER
CONTRACTOR/DESIGNER/EN (NEER
k[ ikVWi.W% 1.5T1Nd.NT'3 NO
N`..AaWN H014 . s
7B-080 041MNTrA'DO SITE 201
78.080 CALLE nTADO IME 201
I, k'1Q uTnTTA. CA 92253
L& yMTTift CA 922":3
(760) r r 7 -1567 LRUf 5407
USE OF PERMIT
Cor_&PdMCL11.L 11 t fO a 3i
.t Z)DITION 0? 1JONdBl1A_:-t1N(1 WALLS ONLY TO CONSTIZUC,'P 5'FOPAt-l? A]Jt7
OFFICE,A11.A. RKWISIONT TO PEWIT 0309-306, PERNOT DOES NOT
NC L,U0F,' 1XI;CY11aHCAL OR EVECTR.iCAL. 2001 C 13C
VALUATION 4,500.00 ISS
PERMA 'YKIR SUMMARY
P1AN t,'H1.CX FILE 101.000.435'-318 IA6.80
CONSTRUCTION M.E 101-0110-419-000 V1.00
STV110NO MOTION FE -P - CORAM I0J-G00.241-000 SM
:IUB-TOT,AL C ONf3nk UCTION AND PLAN C'rT;?C. ,
$119.75
DEC 3DOTAL PFMT%W Tr :S DUE NOW
Q 1uU
CITY OF ! rl t U1 'TA
FINANCE DEPT,
,
RECEIPT
DATE».w. s
Byrj/
DA FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
.Forms & Footings
Ducts
-Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS -
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring .
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
,1
A
Bin #
City of La Quinta
Building at Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 78 -p (S
1W Azsq <4, r-
Owner's Name: , e A( 4A i00XA11-
A. P. Number:
Address: 9 _ d , L c G5 e`l4 00 r
Legal Description'
Contractor:/4i9,UZ&/
upsM e
City, ST, Zip: 4 u. ?-
FTele hone•7 z 7' _=:'•'
Address: _,V$D ,41-L.
r 65,r/- o 5Tgr ze
Project Description:
t=om 49Ek
City, ST, Zip:
I
Telephone _%-01
State Lic. # : (g 3
Arch., Engr., DesignerJe!- tv
City Lic. #: D-; elo7
STgAkF0
Address:
City. ST. Zip: e,
Telephone: 7 =-",. -_
p r— ' 7 tr, ; :.; '; y.. . :;
State Lic. 44 15 q 3
Name of Contact Person: 4-)aL 5
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Deme
Sq. Ft.: nits:
Telephone # of Contact Person:
l Z S,f9 7
Kstirnate alue of Project: 4SD<D
APPLICANT: 00 NOT WRITE BELOW THIS LINE
N
Submittal
Req'd
Reed
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Z/p 0
Item
Amount
Structural C21Cs.
Reviewed. read}• for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Cheek Balance 0
Energy Cala.
Plans picked up
Construction •
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2' Review, readv for correcti s/issueAQ
"v/
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.hI.I, ,
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, readv for corrections/issue
Developer impact Fee
Planning Approval
Called Contact Person
A•I,P,P,
Pub. Wks. Appr
Date of permit issue
School Fees
,
OIL
v
't -r-1-6
T al Permit Fees
Tom Tisdale
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Cities of.
Banning
Beaumont
4.
Calimesa
Canyon Lake
Coachella
Desert Hot Springs
4.
Indian Wells
4.
Indio
4 -
Lake Elsinore
:•
La Quinta
.;.
Moreno Valley
Palm Desert
4 -
Penis
Rancho Mirage
:•
San Jacinto
41
Temecula
Board of Supervisors
Bob Buster,
District 1
John Tavaglione,
District 2
Jim Venable,
District 3
Roy Wilson,
District 4
Marion Ashley
District 5
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
210 West San Jacinto Avenue . Perris, Califomia . Fax (909) 940-6910
December 8, 2003
City of La Quinta
Building Department
Re: Fire and Life Safety Clearance
The Riverside County Fire Department is granting a fire and life safety clearance
for the followingObuil ing-B;--and also the following suites, 108-110, 195-107,_and
--suite-160. Please call -if you should have and Questions.`" r
Respectfully
FRANK KAWASAKI
Chief Fire Department
By So
64,
Terry De ucy
Fire Safety Inspector
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2nd FI., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072