RC (0311-196)78065 Main St Ste 104
0311-196
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chanter 9 (commencing with Section 7000) of Division 3 of the Business and
PrAsionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
4
771883 B 11130/20
Date - `' 1,J I ..•Signature of Contractor!• j i • --- --
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
1' 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.
(1) 1 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 aTAT,E FU14D Policy No. 1440}113Q
(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: ¢,!/c%ti/-rApplicant"I /r . -----^-.----
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, indem
& hold harmless the City of La Quinta, its officers, agents and employe s
2. Any permit issued as a result of this application becomes null and voi•l'
work is not commenced within 180 days from date of issuance of stqh))permit, or cessation of work for 180 days will subject permit to cancellatI certify that I have read this application and state that the above informatiocorrect. I agree to comply with all City,and State laws relating to the buildconstruction, and hereby authorize representatives of this City to enter u
the above-mentioned property for inspection purposes.
Signature (Owner/Agent •. (- 1-- - ate_' I eU t
BUILDING_ PERMIT PERMIT"
DATE VALUATION . -^ LOT ' TRACT
03r'ila.'2C1C
JOB SITE
ADDRESS 7811001 L&I SUMEF..r9 NUTIT, C3,04
APN '
770 21– I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
OLD V0 Wk g11DI.A LLC
I-10: is ,
78-080 CALL1~;1?.E'7 ADO MM 201
78.080 rMI.;k NSTADO EVER 201
LA Q1.TiWA: CA. 92213
..kQ1.1TIvTA, CSA 92233
760)771.2567 (MVi .5107
USE OF PERMIT
COMINU CIAr WYMODF.,L .
bAA .'r uf/ '•[.,,P qq T . "glyla.9'.rg3)± c F3y: 0i3ttL[1 . .p`yy5 g117?m 1t tt)7:3 ^ ( ?37
4St y}?y4 / J•9[.+,
]7 Cp3
C) - .A.3 0CC., 4 L Pie V -I VIR iTt i FIRE' SPRr.R nT BSTI A U IO -J , UOi
::Oi i S.(6ZJJ'rDOOR. S1WrI1,1G-- 64 OCC.)
VALUATION 3.50 -poo 1.1
M_ G frf OF CCONS RUCTTOR
A^ rt p yA yENUM-
yygg ii FEE
P311—Mm E ?iJ.ifl.AL9.d8-HA .Y
CO STRUCTION Ff~E 101-00(.1-418-000 $1,314.50
DAPC1- AN.I.0.AL FEE 101-000-421-000 $52.30
EL FEE 101-000420-000 5102.$$
/
FLUhP1 iT:;TO lar ,E 101-000-419-000 300.50
PLAN CRECK VC, E 101-000.439.318 $1,00ma
STIB- rOTA'L. CO1;9'1 "RU'M7109 AND PT..M MOM
2,W).CA
7X.93 PRE-1PA:11.31'.+ 00,
$0.00
A
'f O A:1:, i'X9X-0t'i' "MS DIT$ Xr. W
2,807.a
pR Q 3 2004
:FINANCE
Y OF LA QUIN +
DEPT.
RECEIPT
DATE..
- ' t7V
BY ,/ — -y
i"
DAT FINALED
- -vfl
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR,
OPERATION
DATE
INSPECTOR
-41 BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 d
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:
• • • �. r r r • r r r • • • • • . . . . . . . • . . • •
I • • � �L
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT M&I AoA PERMIT NO. ( iZaA CT
T JADDRESS %ab,7i i iJ7
o
.INSPECTOR _
REMARKS:
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ANA 18 (Rev 8102) Distribution: WHITE—Office; CANARY—Owner; PINK—Office
.y
-- Certificate of Oc
aF- i
Buildng & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
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
construction and/or use.
BUILDING ADDRESS: 78-065 MAIN STREET STE 104
Use classification. COMMERCIAL Building Permit No.: 0311-196
Occupancy Group: A3 Type of Construction: V 1 HR Land Use Zone: VC
Owner of Building: MARVIN HOMES
Building Official
POST IN A CONSPICUOUS PLACE
Address: 78-080 CALLE ESTADO
City, ST, ZIP: LA QUINTA CA 92253
By: KIRK KIRKLAND
Date: 9-17-04