0109-115 (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
C14 W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Cla-ts Exp. Date
r-- Cy Lr)
W 52123 8
Z ti ' , gate ra ' Signature of Contractor , y' 1
CD O r
� I— � OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury :hat I am exempt from t e Contractor's
~ a License Law for the following reason:
Z( ) 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
U')
N Date Signature of Owner
p c�
C7
U Q 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. 4
CLAR1011DON NNW
(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 Segtiori 3700 of the Labor
Code, I shall forthwith comply with -those prov's)ions
Aa.�*'�
�te:4� ,->r. / Applicant, �l . �, k.
-
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 pertormed 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 r inspection p
,Signature (Owner/Agent) /i r.•-'> I/ -f -Date�/t
1P
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
'12 591; )1 t ` 5 • XINd I 902-.q
JOB SITE
APN
ADDRESS
i '714-447 :I+lIGH`d5rAY 111 MM" P'
&X -0.90.41I6
OWNER
CONTRACTOR/DESIGNER/EN (NEER
iir4:�'� RF.Ai.'rY 1JAR"l:t, FvP%rss;
:1:,3kF"CJMILe w C iJAi-my- }M101 Ww"ANY
125551 013 BLUFF DRIVII.:..,.
.1642-1.A2V.B:rKRT VT., 'SFK 409
BAN DI7OC) CA P2130
LAKE•FORRI'".i CA 92630
..
(94° ')768-89M C .131 sit 4574
USE OF PERMIT as
1619 .AlzAhA.MA
;j"PPedANT lMKLt76'`IDi1f1Df+_NT PER APPRQVFM PL.&NI (FRA E XXPXFsS)
Vt`aL'1'.Ja'tTON I Z006.QP
T'41MI','E 90Mh&dRY
101-00-439-M Vkf.dJ
PLAN !!larCKnnIM
,
. )7101-�40-4 $'+t&, -a')�) p f00
UUNIS R:7L9i�Gy�',ift:'rfTri�c
.
tn.
Ep
Is \.9�'it'RNICA1n IMM L 01-000,42-00, 7. ` S17.50
.50
E3,.M:` RICAL FEE' 101-000-420-000 $60.po
Tyl-I 4ADEF. IG FFM 1,01-000-419-000 $40.09
STItONOMaY..1014 FE R - CO 1010+ -000 -241 -OW $152
SEP 17 2001
CITY 60BK9abadAC1C) 'K' DC 9100 ,Ain PI" CMX
FINANCE DEPT. MW nWPAD FFM
'y
., 1v AL PrwwumsDvf,.N, ow
^iia?1
RECEIPT
DATE_i
BY
U'll
DATE FINALED
INSPECTOR
i' c t -
401
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts -
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
O.K. to Wrap
Combustion Air
Exhaust Fans
F.A.U.
/�/> 10.
vv 666 G
Framing
Compressor
Insulation
/d�/b�
Vents
Fireplace P.L.
`
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall -Int. Lath
_
Z -000y0/ e
Final ���%Z�/
• BLOCKWALL APPROVALS
Final
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 Top Out
Shower Pans
i6/2��/
Plumbing Final
Equipment Enclosure
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
��� �/%�
/D1 G
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring n"
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors _
Temp. Use of Power e �'�
Final
Utility Notice (Perm)
EU
Bin #
�_
it
l�;City of La Quints
Building ar Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
Project Address: 770 447 14k> Y Ilt
Owner's Name: M+14
A. P. Number:
Address: o4paNA-L
Legal Description:
Contractor:Telephone-A7
LqD—z-A—e?(
City, ST, Zip: /_,4 141!Ff2A
41 J,(
Address:2,Z&4? -t.1 41=:±M
LA
Project Description: 7-8WR7y7
City, ST, Zip:
FOAZZT. qZ(v2,0
ALY)
Telephon
!(�400 769 -
............
...... .. .
)2/ta-77 r/07VL.
State Lic. # _R sz, z:5 e)
City Lic. #:
Arch.. Engr.. Designer: JV6,78-P- HAQJPM
Address: LAIC[ A-LI&A-MA
City. ST, Zip: Vk- N&,TrA a(-4 rA TZ&46
Telephone6r1k)
.................
xx- -
.. ....... .......
.. ..... ..
Construction Ty pe: Occupancy:
State Lic. #:
Proj ect type (circle one): New Add' Alter Repair Demo
Name of Contact PersoA:
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person:dJA) (,p!5 -
Estimated Value of Pr 12, p ap
APPLICANT: DO NOT WRITE BELOW THIS LINE tSb
N
Submittal
Req'd
Rec'd
TRACKING.
PERMIT FEES
Plan Sets
Plan Check submitted
Item Amount
.Structural CaIcs.
Reviewed, reidv for corrections
/e -
Plan Check Deposit
Truss CaIcs.
Called Contact Person
Plan Check Balance
Title 24 Cates.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
I
Grading plan
2" Review, readv for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
Review, ready for correctirs/issue)
Developer Impact Fee
Planning Approval
Called Contact Person
A. 1. P. P.
Pub. Wks. Appr
Date of permit issue
School Fees
tz
Total Permit Fees
Ski �/ �iY l�/7�N 0 (O.,67,C -5N�
RIVERSIDE COUNTY FIRE DEPARTM6,
FIRE PROTECTION -y'
JOB CARD
THIS INSPECTION RECORD MUST BE
AT JOB SITE WITH AN APPROVED
SET OF PLANS
Owner rra»a't 3h-92 Date
Location -8-447 do IL600 III r �:� Z)
Case No. LAD -el - W- o59
Sprinkler Company
d jA
Underground Static Date Inspector
(200 PSI For 2 Hrs. Prior to Inspection Time) ,
(Center Load Pipe Only, Joints and Thrust Blocks Must Be Exposed).
Underground Flush
Date
Inspector
Final
Date Inspector
Overhead 9!sNe
PSI For
� D e
Inspect
(200 2 Hrs. Prior
to Inspection Time)
0
Date
Date Inspector
Overhead Final
Inspector
Fire Main Installer
Date
Underground Static
Inspector
(200 PSI For 2 Hrs. Prior
to In action Time)
(Center Load. Pipe Only, J ' 'Its Thrust Blocks Must Be Exposed).
Date
Undergrour
gteftlush
Inspector
Extinguishing System Installer
Final
Date Inspector
Fire Alarm Installer
Final
Date Inspector
Tank Installer
Final
Date Inspector
FINAL for OCCUP NCY p�,(�
InspectorOdte
DO NOT OCCUPY THIS STRUCTURE. UNTIL
AFTER FINAL INSPECTION.
264-159 (Rev 10/97)
Certificate of Occupancy
�g
City of La Quinta
Bu- ilding and Safety Department �°eMom
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 78-447 HIGHWAY 111 SUITE D
Use Classification: TENANT IMPROVEMENT, FRAME EXPRESS Bldg. Permit No.: 0109-115
Occupancy Group: B Type of Construction: VN Land Use Zone: CC
Owner of Building: M & H REALTY PARTNERS
Building Official
Address:
12555 HIGH BLUFF DRIVE
City:
SAN DIEGO, CA., 92130
By:
DANIEL P. CRAWFORD JR.
Date:
10/17/01
POST IN A CONSPICUOUS PLACE