0307-253 (RC)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
v
76639 � /t B MC 11 Qtif�4fa�
Date Signature of Contractor dlf,'�%(ate�„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).
( ) I am exempt under Section B&P.C. for this reason
Date Sianature 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 STAI'I3 FU11j) Policy No. 044400208441 .
(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 withy`those''pro islo - .
Date: J - Applicant-
Warning:
pplicant �1s�r r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify—
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes•null and voidiif�
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellatioY
I certify that I have read this application and state that the above information Is
correct. I agree to comply with all City, and State laws relating to the,buildinLg
construction, and hereby authorize representatives of this City to enter upoh
the above-mentioned property, for inspection pGrposes. ,-
f A�J
1 Signature (Owner/Agent) 1` 11 I Date M /3' • S.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT, �7 TRACT
,
SIOAOO.00 P2 PIW 19018
JOB SITE y
ADDRESS 7 -� I. HJ(Jr Ay 1], 1,
APN ? ,
' }Q -• ��
'OWNER CONTRACTOR / DESIGNER / EN 1NEER
M H;i?o-oplaTy IMMIX F%MUMSE8
78.40113T.HJ4°AY,1 i 1 441 CO3 MERCT'AL WAY•
LA Q.CJMTA Cit. 92253 LA RA CA 9063
(562)690-9559 C8L# '18D
USE OF PERMIT
COMMCUL RMODY..L
STARBUCK'S KI®SIC (163 SQ. FT. ADDIT10N &DELTA 51 MI-IS10143
TO VON`$ GROCERY STORE
CONTRACT.AMOURT I4,4(iA.Dtf W
XFMIAIED. MST OF COiV9I17TJ'C3100
�.aD,OSItP.I>�
pr'F.APdrFEE SUIPAIVUR ''
PLAN CHECK "M. 1Ci1-�(3C1��S-�1i3 1i3�
CONSTlZurfION S?F1Ir 4117,00
MT!CHANICAL:KEE 10170006421-000 $IS tl14
EL9CT1UCA,L,F2T: 101-'(kt30 4L -t10iJ $1846
PLUMBING FEE .. 101-000.419.-000 122.3i1
STRONG MOTION FEE P COMIA 100-000-24.1-000. Via. to
1317B. -TOTAL C.OMMF:7GYTTONMM PLAN N la=
$256.91
LEMS PRE-PAJD FM -
/AA
��a�%pVAXxe��3Lh.K q^Y
0 6.2003 JJ
�7 t
�IKw�1a�.1
.AUG
CITY Cr- LA L?U ITA
Dirl
RECEIPT
DATE ' ""
BY
DATE ANAL D
INSPECT R
S1 • to ' ;,
F/ 'I
r 3
.
IV,
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 4
BLOCKWALL APPROV LS
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 O
Utility Notice (Perm)
COMMENTS:
F2
X
X
04/1512003. 14:16 7607777011 LA QUINTA PAGE 02/02
Bin #
C3 C-11
City of La Quinta
Building as Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinw, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: -'76,9-71 H IGH k4,-( 1114
owner's Name: �} p
A. P. Number:
Address: %, -- 1 14 1G i- W4Q 1 1 1
Legal Description:``
tf Croy, ST. Zip: L� QUI I�� c-.6 9/f,42Qj3�
Contractor: E 14 �N� I�{j
FTcicphone: 76O -'-' 71' 4�,�'e
Address; 44..1
Proiect Description: B �
Ciry. ST. Zip: L-,.,!-
aTelephone:
Telephone;5b2• o4a • sS�11
State Lic. p :�j%(p(O�'j�
Cin- Lic. z:
Arch.. Engr.. Designer;
Address: 12 1 . IMS IPL H10HV1,&-f
Cita. ST. zip: NT,o 1 St—IQIH c&gC;670
Telephone: t5&2'
Construction Type: Occupancy:
State Lic. il:
Proiect type tcircle one): Ncxt Add'n \ Itc►ep (Demo
Name of Contact Person: t?p'JOHH•l
Sq. Ft.: 51,7;;T
a Stories I
k Units:
Telephone k of Contact Pcrson: C✓tp`' 8ZP,--3 •
'VEstimated Value of Proiect
APPLICANT: DO NOT WRITE BELOW THIS LINE
P
Submittal
Req'd
TRaCK NG PElt�11T FEES
Plan Sets
�7Recd
2
Plan Check submitted ( Item
Amount
Structural Coles.
Reviewed, ready for corrections Plan Check Deposit
Truss Coles.
Called Contact Person Plan Cheek Balance
Energy Coles.
Plans picked up Construction
Flood plain plan
Plans resubmitted tMechanical
Grading plan
2" Review. ready f carreelions/ssuc o Electrical
Subcontactor List
Called Contact Pers 3/5- Plumbing
Grant Deed
Plans picked up 57,1- S.M.I.
H.O.A. Approval
Plans resubmitted -Navot 7/1 Grading
IN HOUSE:-
s" Rrvirw, ready for corrections6ue. )Developer Impact Fee
Planning Approval
Called Contact Person
Pub. Wks. Appr
Date of permit issue 8GG
School Fees
Total Permit Fees
N 07-C = PCez L,417Cti E� vt,.s T �rr'r' E a J f?jF V JV--
-7—r%&MP R* 0655 oN R/4 --j G �57 c ry t6d3-
Tom Tisdale
Fire Chief
Proudly serving the
Unincorporated
Areas of Riverside
County and the
Cities of -
Banning
.y
Beaumont
Calimesa
Canyon Lake
4.
Coachella
4 -
Desert Hot Springs
Indian Wells -
o.
Indio
4.
Lake Elsinore
4.
La Quinta, -
4.
Moreno Valley
Palm Desert
4.
Perris
4.
Rancho Mirage
San Jacinto
Temecula
Board of Supervisors
Bob Buster,
District 1
. JohnTavaglione,` '
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 est San Jacinto Avenue • Perris, California 92570 • 909) 940-6900 • Fax (909) 940-6910
August 18, 2003
City of La Quinta
'Building Department
Re: Fire and Life Safety Clearance
The Riverside County Fire Department is granting occupancy fire and life safety clearance
for the following Starbuck's project located inside Von's Store at 78-271 hwy 111, La
Quinta.
FRANK KAWASAKI
Chief Fire Department Planner
Bya
Terry De oucy
Fire Systems Inspectors
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2n° FI., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072