PLBG (0403-045)78065 Main St Ste 100
0403-045
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
r 883/ :B '-1`If3
/ 7
Date f ignature of Contracto_
` 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 xTATF FUND Policy No. r.If31: 9-G3
(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 subiect to the
workers' compensation laws of California; and agree that if I should become
subject to the korke(s' compensatiomp ovisions of Section 3700 of the Labor
Code; I sl all orthwith•comply with -those provisions.,
,,,D e: ;%'ffv' t e; Applicand-L'4f
Warning: Failure to secure Work s' 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 hereby5 authorize representatives of this City to enter upon
the above-mentioned property for inspection•purpos4s.
Signature (Owner/Agent)' Date
r
_B;UILDING PERMIT PERMIT"
DATE '° I i rVALUATION LOT (M03r04 TRACT
JOB SITE APN `
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
LLQ-LMgTA. CA 92253 LAQU:WTA. C.A. 92253
(760)771-2567 Galt 44 5407
USE OF PERMIT
I X2 1; i t3 •
tidS'i'1' L,LA` IO'I'i OF 1600 GALLDN OR lid'f'BRC.U`1'C.RAT Sf3ITa Icc
(JAZZY t_ RIESTAiJR.AWT3 \ PER PLAN AND ,K ALTH DEPT APPROVAL
V'ALWATION,
Z000,0.9 I'S
USOr."MUM CO.T OF CGI1tSTRL3[7110N
WWAARY
PLUMI KHO MS ' 101.000.419.000 $77,00
e
e.
1 Ii
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;'. f ":t1. :?2if ; : ' ?'EMS :l;'JUR Now
MAR 16.2004 U
CITY OF FIPIANC DEPT. A9
RECEIPT DATE ' / BY 4111 DATE FINALED INSPECTOR
tC) oo
S27.00
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 I
POOLS - SPAS
BLOCKWALL APPROVALS
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
COMMENTS:
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)
Iv
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PLAN CORRECTION
Plan Check # NO3-063
DBA Jazzy's Cafe and C
Plans Submitted by F
Owner
The plans are now approved subject to the conditions lists
1. All floor, wall and ceiling finishes in food service areas
waitress and self service stations such as drink dispenser
Date . 9/17/03
78065 Main S "C100", La Quinta
Phone (760)320-4628
Phone
and the attached
smooth and easil
sheet
2. All food and utensil sinks must be plumbed to floor sinks through approved air gaps. The mop sink must be
of the floor basin style. Behind all three sinks In the splash zone the finish must be water proof to a height of 8'
(e.g. FRP/tile) - - .
The trash enclosure must be finished so that the interior floor and walls are smooth and easily cleanable.
eal these interior surfaces with an aooroved twn nart pnnvv
4. All exterior and restroom doors must be self
5. T
shift
Exterior doors must also
sealed against entry by
number of lockers provided shall -be equal, or greater than the number of workers assigned to a peak
e. An air balance report will be required prior to -completion of the final inspection
7. Sneeze protection will be evaluated for efficacy at the time of initial Inspection . Corrections will be
addressed at that time.
8. Approval of this plan does not include approval by local land use, water or sewer agencies. Prior to
commencing construction or undertaking improvements, submit these plans to the Riverside County Land Use
Agency located at 82675 Hwy 111, Room 201 Indio CA 92201, phone (760) 863-7000. A facility may not
receive an Environmental Health Permit without this approval, which will be verified prior to the final inspection.
CONSTRUCTION INSPECTTONS: Contact the Plan Checker_for a Preliminary Inspection when
construction is approximately 80% complete, with plumbing, rough ventilation, and rough equipment installed.
Request for inspection should be made at least five (5) worldng days in advance. A compliance guide is attached
to this plan correction sheet. All construction not otherwise addressed on the plan correction must be performed
in accordance with the guidelines set forth therein. A FINAL INSPECTION MUST be made upon completion
of ALL work including finished details. APPROVAL to operate shall not be granted;' or remodeled areas
approved to operate, until the facility has passed the FINAL INSPECTION, and "APPLICATION TO
OPERATE" has been completed and PERMIT FEES have been paid.
Request for inspection should be made at least five (5) working days in advance.
PLANS CHECKED BY David E. Day Phone (760) 320-1048
I acknowledge the corrections noted herein and as indicated on the plans and agree to incorporate
them during construction:
o
Signature ( i .
Company "FP-AiJe4!rX--,0
Date cel 9 •449kD3
ILL
"14 rr--:
welling, IVIN Sne Prep., etc.
Proposed Bottom Tested Depth
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
or L -2—
DEPARTMENT OF ENVIRONMENTAL HEALTH
Signature ofAp"01.16ant
APPLICATION FOR WASTE WATER DISPOSAL
I Date
APPROVAL
.(3) Pit Diameter
.0. Pits
`*PPLICANT Submit this form with four copies of a SCALED plot:'p1667?(fs-20' to 1'=40' SCALE) drawnto: specificationsa,s1ndlica c
check list. A hon-refundable"filing fee is required when the application Is submitted. "Check must be made payable to the County of Rivirsid
application shall remain valid for a period not to exceed one year from date of payment.
CHECK BOX IF REQUIRED
',Other.
LMS #
i
-'o
Q Detailed Contour P16*1lPlans: Required (11 `to 5i
' lntervai)
h
information is provided and the fee paid. Resubmittals later than 90 days
Agent, Contractor, Contact Person
W4 4 4 t)
Address city -
-79-47qO Ile
StateZip
Other
Im
Z
Q Holding Tank Agreements Completed
Q. Staff Specialist Lot Inspection Required
0
Q Certification of Existing S.D. System Required
Thomas,-BrosrRagi9l Grid
Owner _ 4
Address city
'State ZIP.'_
Wom
El WQCB Clearance Required
"Ll Date Lot Inspection'Ietj
C_ p, & Initle
(Attach. for DOH -SAN -007: Santa Ana Region Only)
Date: Dil.'D
.7
Remarks:
7
A
❑ Solls'Percofation Report Required
r'a 1 an"A" ppmved:, V
'
E) Special Feasibility Boring Report Required
-Maintenance Booklet
0
Job P perty_ Address
1144 I-ew
city,
E) Rereview Required Initials Date
Please call 24 hours PRIOR to Inspection. -24":i
der
C/42 Soils Percolation Boring Report B
ILLIQ
Lot Size
Water Agency/Well
of ermiI. PIP, S P, PUP, etc.
Legal Description
D&,
Type of System(s)
U)
(1) Septic Tank
ire,
124magalcand
epla
iiepla6ement
E] Holding Tank' "C] R ant
IW
Z
0
U.1
U)
1-1111114112 MU -6 CIRRI 6hrm--
1r*0.4`"PA"=0RVm9`P`11dk floor -&nine In food p0e -a as
$fl 11191 0 * ?
tl.7777=7 7 . . . - r
atrrr 0, f s
.—V
N
This application Is PPROVEDI ENIg f ho'lipategi
Igr 'd I
tgB,rd gtW al
oil' .. T549
SECTION ardin I
)ry checked In:
'o
ghe ate
above,
on the comp us g
In SECTION
p
ac,
!ON B ab in a e'lndicated
accompanied
R
nets Sq :t to o the above.
C above. A building permit 1' us avenue Code
designed system.
100% expansion area.
(1) Septic Tank must be 100,0nirn
(2) Leach lines must be 106-,niin'l
mJm'tirorri an Welie; Including X1 Dat
.e'' a
r
area.
4p ......
(3) Sewer lines mu ...
at be 60' mInImwf'frorfl`a'_nyweIIs.- .!4."
j IP
Seepage pits must be 50' minimum Including expansion RIVERSIDE .:-.'K . 909-9554980
(4) Se from ani'livells'
,area.
V
tj 7
`
NDIO.ft 760=863-7000.
Signature
SOUTHWtix'909=600.6180
..6 909w ou
A, _W" jii
thli
I
ft
welling, IVIN Sne Prep., etc.
Proposed Bottom Tested Depth
or L -2—
Signature ofAp"01.16ant
Z
0
I Date
design for slope:
.(3) Pit Diameter
.0. Pits
FOR OFFICE USE ONLY
Seepage Pit
CHECK BOX IF REQUIRED
',Other.
If any box is checked, this application shall be considered rejected until the
i
-'o
Q Detailed Contour P16*1lPlans: Required (11 `to 5i
' lntervai)
h
information is provided and the fee paid. Resubmittals later than 90 days
after date noted below may require repayment of fees.
Other
Im
Z
Q Holding Tank Agreements Completed
Q. Staff Specialist Lot Inspection Required
0
Q Certification of Existing S.D. System Required
Thomas,-BrosrRagi9l Grid
Wom
El WQCB Clearance Required
"Ll Date Lot Inspection'Ietj
C_ p, & Initle
(Attach. for DOH -SAN -007: Santa Ana Region Only)
Date: Dil.'D
.7
Remarks:
7
A
❑ Solls'Percofation Report Required
r'a 1 an"A" ppmved:, V
'
E) Special Feasibility Boring Report Required
-Maintenance Booklet
'SIGNATURE
wcu
'ec nly_1, -.,; P", !:,% t.,I 1
Plan C
'h " k 0'-4- i!: Dae,, - ,:;`T,3'
u':
C3 Final Inspection by'Departnienfbf En"'vi'm'h rh"e%n'ta'.1'.'He'a1%
E) Rereview Required Initials Date
Please call 24 hours PRIOR to Inspection. -24":i
wirvIll"til-i Alatefda-vulok
C/42 Soils Percolation Boring Report B
LIctPmject' ate: q
Soils Map Page Soil -Type Approved
B n
No. of Systems
Type of System(s)
No: Dwelling Units
(1) Septic Tank
Soil Rate
124magalcand
epla
iiepla6ement
E] Holding Tank' "C] R ant
Bedrooms, Fixture Units
.roQ,
rease Int
ase& ,
0 New Addition
Addition
Q Existing ElCon 6 'i
ct to Sm]w:i'e
n:e
tt S
c 0
.0i
a
a
Sq. Ft. •
Total Linear
Sidewall Allowance
Bottom Area
Ft.
ft. rock/ •"sq. ft. running"I't.
Install d
ofE
In atI :T 6sted Depth
Q N/A
with miln. Inches,mck In
below.'.d , railines*
IW
Z
0
U.1
U)
1-1111114112 MU -6 CIRRI 6hrm--
1r*0.4`"PA"=0RVm9`P`11dk floor -&nine In food p0e -a as
$fl 11191 0 * ?
tl.7777=7 7 . . . - r
atrrr 0, f s
.—V
N
This application Is PPROVEDI ENIg f ho'lipategi
Igr 'd I
tgB,rd gtW al
oil' .. T549
SECTION ardin I
)ry checked In:
'o
ghe ate
above,
on the comp us g
In SECTION
p
ac,
!ON B ab in a e'lndicated
accompanied
R
nets Sq :t to o the above.
C above. A building permit 1' us avenue Code
designed system.
100% expansion area.
(1) Septic Tank must be 100,0nirn
(2) Leach lines must be 106-,niin'l
mJm'tirorri an Welie; Including X1 Dat
.e'' a
r
area.
4p ......
(3) Sewer lines mu ...
at be 60' mInImwf'frorfl`a'_nyweIIs.- .!4."
j IP
Seepage pits must be 50' minimum Including expansion RIVERSIDE .:-.'K . 909-9554980
(4) Se from ani'livells'
,area.
V
tj 7
`
NDIO.ft 760=863-7000.
Signature
SOUTHWtix'909=600.6180
..6 909w ou
A, _W" jii
thli
I
ft
Proposed Bottom Tested Depth
or L -2—
Z
0
Leach lines/bed special
design for slope:
.(3) Pit Diameter
.0. Pits
Pit Below Inlet (131)
Seepage Pit
MaxIm6m.,
',Other.
—
Applicable
h
Total Depth,
-'AllowableI•.n
ID
A,
0
.0
N/A verburdeh Factor
6.
Depth A.
W1
1 211,
Well 'Rie'viewApproved: 3
SIGNATURE'
Date: Dil.'D
.7
:41
6 8 n g
7
A
r'a 1 an"A" ppmved:, V
Dat6:_
'SIGNATURE
wcu
'ec nly_1, -.,; P", !:,% t.,I 1
Plan C
'h " k 0'-4- i!: Dae,, - ,:;`T,3'
REMARKS-'.
. . . . . . . . . . . . . .
wirvIll"til-i Alatefda-vulok
IW
Z
0
U.1
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1-1111114112 MU -6 CIRRI 6hrm--
1r*0.4`"PA"=0RVm9`P`11dk floor -&nine In food p0e -a as
$fl 11191 0 * ?
tl.7777=7 7 . . . - r
atrrr 0, f s
.—V
N
This application Is PPROVEDI ENIg f ho'lipategi
Igr 'd I
tgB,rd gtW al
oil' .. T549
SECTION ardin I
)ry checked In:
'o
ghe ate
above,
on the comp us g
In SECTION
p
ac,
!ON B ab in a e'lndicated
accompanied
R
nets Sq :t to o the above.
C above. A building permit 1' us avenue Code
designed system.
100% expansion area.
(1) Septic Tank must be 100,0nirn
(2) Leach lines must be 106-,niin'l
mJm'tirorri an Welie; Including X1 Dat
.e'' a
r
area.
4p ......
(3) Sewer lines mu ...
at be 60' mInImwf'frorfl`a'_nyweIIs.- .!4."
j IP
Seepage pits must be 50' minimum Including expansion RIVERSIDE .:-.'K . 909-9554980
(4) Se from ani'livells'
,area.
V
tj 7
`
NDIO.ft 760=863-7000.
Signature
SOUTHWtix'909=600.6180
..6 909w ou
A, _W" jii
thli
I
ft
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1. REFER TO SPE.QnCAT10N SHEET NO. 57218
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3. REFER TO SPECIF1CA110N S44EEI ND. 5-251
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EXCAVATION 9DECIFICAU MS
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THREE MANHOLES EXTENOFA M (MADE
DESIGNEE) FOR DIRECT H-20 LOADING
OF MANHOLE EXINSIM
2000 TKU 3000 GALLONS
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P.O.' BOX )SO2
MGMAND• CA 92346 1
909 793-7602 1300 945-8265 }
Fax: 909 793-1283
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