RC (0310-267)78065 Main St Ste 200
0310-267
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 771685 B 1'i 0/0!
Date - l Jf 1, Signature of Contractor ¢ 'r° • `{ r_:
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 Policy No.
STATE r,UND 144DI25-03
(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:' pplicant 11 IV
' 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/Agent) 1r ®%%+-✓ % -' / DateZ,_1 /. ' t
- BUILDING PERMIT PERMIT#
i r
DATE VALUATION LOT TRACT
JOB SITE !
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
OLD'.[ OWNT LkQU.-I T ALx.0
1AAR I I-10Nffi;1
78-060 CALI.,L!.27J ADA'VIM 201
7-080 CAUZ EbTIND01,701201
LA QI:I"INTA • CiA. 92253
Lk (;i`" NTA. CA 9.2253
CICO)?71-•2567 r`HJJI 340
USE OF PERMIT
C01tff:> EIt€ VL 1tn40 '3EL
COMM- T.I. HOGS131V. krk1 TtESTAIllUi.NT • 7,393 ,0.,3 UCG.,
TYPE V-1-14ilV11 FIRE SPI?INKLi?1!SURSTITUTIONO)R 3 1dOURPE1
CBC SECTION 303. 2001 COEWS
CONTRACT MOUNT 106,000.00 LS
W1:37",=.1) cogr t5r C IC.)I NTYRU{"'T:iO
105,M0.00
CONSTIIUCTIOhl PEE 101.000.418.000 $660.30
PLAN C.HWX FEE 101-000-439-318 $395.20
MEC RA14ICAL 'FEE 101-(7`00.421.000 $63.00
ELIEC TRJ(_* kL ?EZ 101-000-420-000 $164.00
PLUMBINO FIRE 10 1-000-•415.000 2265,75
3' a R(' w4f-voiR 'ar F m t?.. r ° tf it Q0-000-241-00 $22.26
FEB 11 2004
CITY OF LA
QUINTA
FINANCE DEPT.
SUTa-110TAL. CO1JM_1='S014 AND PLPM ti:HI C
m, -J69.71
LESS X'':I"E-PAID EXIM
MOO
:DUE NOW
sI176.9:7I
1, h.r, ixemres.i,stive detailing deferred
to -
,,- a separate*penM 41.y
Fire Department-NDn*St-rV, uraiioa`Pprov6NI
`Ovior. to..,CA,
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
t
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 0Compressor
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:
t
10ij,
, NQ, - 30 '
=DAY,TEM
0
PORARY.
Certificate of Occupancy
EXPIRES OCTOBER 13,.'2004
OF
T4
Building &Sbfety Depadme'nt
This Temporary Certificate, issued pursuant to the requirements of Section 109 of the California
Building ".Code,.,, and with the concurrence of the Public* Works Department and Community`
Development. Departmen't, -certifies. that The Hog's Breath 'Inn, at the time of issuance, was in
compliance with the provisions of 'the Building,Cbde and the various ordinances of the City
regulating. building construction and/or use.
BUILDING -ADDRESS: 78-065 Main Street Suite 200
Use classification: Restaurant
Building Permit No.: 0310-267
Occupancy Group: A-3 Type of Construction: V-1 HR (Sprinkler substitution Per 6EFC 508)
Land. Use Zone: VC
Owner of Building: Old Town La Quinta LLC Address:18-015 Main Street, Suite 205
City, ST, ZIP: La Quinta,, CA 92253
By: -Greg Butler,. Building & Safety Manager
Date: September 13, 2004
'Building Official,
POST IN A CONSPICUOUS PLACE
611
FLL 6-,
0
t
10ij,
, NQ, - 30 '
=DAY,TEM
0
PORARY.
Certificate of Occupancy
EXPIRES OCTOBER 13,.'2004
OF
T4
Building &Sbfety Depadme'nt
This Temporary Certificate, issued pursuant to the requirements of Section 109 of the California
Building ".Code,.,, and with the concurrence of the Public* Works Department and Community`
Development. Departmen't, -certifies. that The Hog's Breath 'Inn, at the time of issuance, was in
compliance with the provisions of 'the Building,Cbde and the various ordinances of the City
regulating. building construction and/or use.
BUILDING -ADDRESS: 78-065 Main Street Suite 200
Use classification: Restaurant
Building Permit No.: 0310-267
Occupancy Group: A-3 Type of Construction: V-1 HR (Sprinkler substitution Per 6EFC 508)
Land. Use Zone: VC
Owner of Building: Old Town La Quinta LLC Address:18-015 Main Street, Suite 205
City, ST, ZIP: La Quinta,, CA 92253
By: -Greg Butler,. Building & Safety Manager
Date: September 13, 2004
'Building Official,
POST IN A CONSPICUOUS PLACE
611