RC (0312-263)78015 Main St Ste 111
0312-263
LICENSED CONTRACTOR DECLARATION
' J hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9°(comme7t1
ncing with Section 00) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
%771883 B 11 i30/0."
Date rte'// Signature of Contracto L2 ~ 1
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).
O I am exempt gunder Section B&P,.Cn,, fo , tthis reason
Date j% ' : Ur (' Signature .of.,ewner t/ !A", /✓
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 MTE FUND Policy No. 1440#25-03
(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: //• Ab 16 plicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to' the conditions and restrictions set forth on his
application. `
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyforinspection purposes.
Signature (Owner/Agent) ✓ 'J 01t ' Date G >✓V
BUILDING PERMIT PERMIT#
DATE VALUATION LOT4 r,3 TRACT
JOB SITE
APN
ADDRESS 7"15 ilk.;N:8"'.1'37.1F..1.'•.TSU12! III
OWNER
CONTRACTOR /DESIGNER / EN INEER
Nl a lfii E'd 12'' '1 v1 A3'i DTC
MIARtT19110MEs
78-060 CA LLE E,JIADO ME 201
78.080 CAME B S:I:A DO _T'E 203
LA QUJN'rA. CA, 9IZ253
i.,r$.4zaJZA rik CA 92253
(760)771.2.467 CBLO 540'
USE OF PERMIT
CC3h -A-M- AJ 1 17U1. 1 1.
ADDITION OF NON-Bf!A}'tiTtt:iWALL UNL1° TO CONSTRUCT OF'FYCEA.RF—k
REW0,30N TO PERMIT 0310.053, PEAMIT DOM NOT INCLUDE
MCt.;1.1J". ' I::A.L. 2001 CBC
VALUATION 4,=.0.63
EMlsgi4UD CONT OF C•ONS'1:`1 iiY .` ON
PLAN CHECK IEE 101.000.439K318 146,010
CONSTRUCTION -19Z 101-000,418-000 Pri.00
ELECTRICAL FEE 10140(40-1-2O-OGO 861;15
ST,RC ING :SIO"f I014 FEE C;OiA.M '10t1-000-241-000 $.95
I'Ia LTf."'1iOW .SND PLM CHECK '.f K
x"141.50
D o J ESS PRE -PAID FMS
$0.00
DEC 3 0 2003 Al, P ;. Arr .-s DUI, NOW
$141.50
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE,1
.rye
BY .—.-- —_
DATE FINALED
INSP OR
/ "
-2 17,
M
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
Nreplace 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:
A
x
Bin #
a
City of La Quints }f
Building et Safety Division
; P.O. Boz -1504, 78-495 Cabe Tampico'.
Permit #
_;
Quinti; CA 92253 - (760) 777-7012 - -
w/a'a63
Building Permit Application and ' Tracking Sheet .
Project Address:
sl ` 'r:,' ''
Owner's Name: • , 6W
A. P. Nuniber
;` '' '= - ---X-
r :
Address: j>
- 9 'S f`?4 Go
4. L
Legal Description:
_ _ -' .. _
City, ST. Zip:/, u, ( • ZZ,S
Contractor. M 4AUT&I INVE.5t-M
FTelephone: %-/- Z to -'' '*•- _ '.
Address: _Q o /-1-
e rXDO Z8 /
Project Description:
%&l(rvV dirk
City, ST, Zip: 4 T'fV 4A
Telephone: % /- 15rlv
State Lic. # : 5:5 3
City Lic. #:C_;;%071
Arch., Engr., Designerjef- tV
STOuCFO p
G
Address:
I
City, ST. Zip: LCSL ZZlvO
Telephone:
p '179
.
`.,,K..;_ -=
Construction Type: Occupancy:
State Lic.s' ,,,:,:./-::. c
Pro ject type (circle one): New - Add'n Alter Repair Demo
m
Nae•of Contact Person: &)aL 5 `
Sq. Ft.: it -2 2- S # # Units:
ced;Value of Project:
Telephone # of Contact Person:
>e
APPLICANT: DO NOT WR
Submittal
Req'd
Reed
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
2/1/0/03
Item
Amount
Structural Cafes.
Reviewed, ready for corrections
Plao Check Deposit
,
Truss Calcs,
Called Contact Person.
Plan Cheek Balance •
Energy Cafes.
Plans picked up
Construction v
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for correcti "rs/issu L
Electrical 0
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.'2- •
'
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A•I•p p
Pub. Wks. Appr
Date of permit issue
School Fees
V
T `440
Total Permit Fees
Tom Tisdale
Fire Chief
Proudly serving the
Unincorporated
Areas of Riverside
County and the
Cities of:
Banning
Beaumont
Calimesa
Canyon Lake
o.
Coachella
Desert Hot Springs
Indian Wells
Indio
Lake Elsinore
4 -
La Quinta
.g
Moreno Valley
.;.
Palm Desert
4 -
Perris
e.
Rancho Mirage
4;.
San Jacinto
d•
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 Forestty and Fire Protection
210 West San Jacinto Avenue • Perris, Caf omia 92570 • (909) 940-6900 • Fax (909) 940-6910
December 16, 2003
City of La Quinta
Building Department
Re: Fire and Life Safety Clearance
il
The Riverside County Fire Department is granting a fire and life safety clearance
for the fo_llowing_project Old Town La Quinta for building((Bj; suites4_ ^19Z 17
T 103, I04, 106, _and _1.1.1. Please, give me a phone if you should have any questions
Respectfully
FRANK KAWASAKI
' Chief Fire Department
By
Terry
Fire Safety Inspector
EMERGENCY SERVICES DMSION . PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2nd FI., Indio, CA 92201 . (760) 863-8886 • Fax (760) 863-7072
1/8" = 1'-0" IA
SUITE A 1 1 1 ADDENDUM A 12/04/03
on john stanford • architect
as 73-350 el paseo suite 207 palm desert, ca.
tel. 60 776-8478 fax 760 776-8477