0311-208 (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
6406983 r C9 B HIC 04/30/2f
Dater,
Signature of Contractor
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 3T.ATi? I'tIND . Policy No.
(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' compensationprovisionsof Section 3700 of the Labor
,Code, I shall forthwith comply with thoseYprovisions..,.
Date: / " 7 Applicant
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 toy+1'
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 properttyf7 inspeedtion purposes.
Signature" (Owner/Agent) / 1 A- `� Date
,yea
BUILDING PERMIT PERMIT#
DATE 01/061110C VALUATION $44,71LOT TRACT
JOB SITE
ADDRESS 78"i% .�"Lf!,ti�.'Ii9.A� _
APN .. ...
OWNER
CONTRACTOR / DESIGNER / EN (NEER
..a T?.Jpo .", ` N1.ANAGT ,idT `[,1; .
X.T. A CC VISMXTC'3:IO)v
12555 DR * rB 295
PO BOX 490
S"M'MIGO CA 92130
C.A714K)RAvCTTY CA 92234
(760)325.4075 f::BL-4-- 6022
USE OF PERMIT
COU-MERMAIL h1="EvFt DEL
COMtl.I!;RCIAL, k.I:fZIODEI, (BACK PAIN a1STI`fLiTP 1-1) OcCGtPA:NrY,
T'sf&'&W C'01487. OCCUPAN 1' .LORI'-+ 22, 2001 COC
VAr,T.,ATION �id,7lli 0R I.ii
ESTU".11M MST OF COVISTRIYU JIM
44018.00
M EV, HANI(-'AL I=,t,2 IM -000-421-000 $19150
E3..'W'I'.RICA 3, FEE 101-000--/1.20-000 $34.50
PLUMBING FEE 101.000.419.000 s2t,00
STRONQ MOTION FEE:- COMM I00 -000-M1-000 $13.02
PUN14 CHECK RE 101.000-439.315 3248,30
'CONSTRUCTION FEE: 101-000-418-000 �53a.i10
y
1U OT Y CO1L�.�'�;.C.7i,'`T101 .l�I�ID PJ:.A, C:}3R.71C
�'k8I'-RAIDF S'
MCO
EFLESS
06 2004
OErtUh
TA
FINANCE- DEPT.
RECEIPT
DATE //
BY / /
DATE FLAAL
INSPECT
I
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
BLOCKWALL APPROV LS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out / 6
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: '�i� /171,59/ ` I
/ / �/I�GL ?Q
y
girl#
a ae_ ow-TIVS-mare Cityulnta
ofLaQ'
Building at Safety Division
Permit # P.O. BOX 1504, 78-495 Calle Tampico
y' La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Project Address: % 416
1"W" i � % Owner's Name: J r /yl t R �'G T i°�ar
A. P. Number tgtJ
Leal Description: Address:
oa Ivg- bedl- 12-ssS r l BlvFF,�,t
City. ST. Zip: ,L i4 G?V r AJT `Z' 'ot
X Contractor j0 HN C
;Telephone: 7 i / 3 O y� ''".�;{-c•
x Address:
S 3 ^(000 Project Description:
z City, ST. Zip:4p_ QV l� CA
X Telephone:
X State Lic. # : City Lic. #: .._
Arch., Engr., Designer.
Address:
City, ST. Zip:
Telephone: w _W_.
.:: •• ; :;r_.
Construction Type: Occupan
State Lic. #: �8':tS' �:: ; .: cy:
Projecttype (circle one): New
-Add'n Alter Repair Demo
X Name of Contact Person: J0 Go"r sr av _77
M PF/��5 M .4AtA6w/L Sq. Ft.:7) D # Ston k Units:
X Telephone # of Contact Person: CSC S ;�, 69 � �7 stimated Value of Proiect:
41
f S'5 9 y 3a -Z Z 76 zY 711
APPLICANT: DO NOT WRITE BELOW THIS LINE
# Submittal Req'd Reed
TRACKING PERMIT FEES
Plan Sets Plan Check submitted
' em Amount
Structural Cates. Reviewed, ready for corrections ///�
Plan Check Deposit
Truss Calm Called Contact Person
/ Plan Check Balance Z 8.30
Energy Gales Plans picked up t�
^'' I*uAsr /L l) Construction 39Z.60
Flood plain plan Plans resubmitted �
' '� 1lfechanical�ti'art� 1q.��
Grading plan 2'' Review, ready for correctionsrissue
Elcetrieal �j � S'a
Subeontaetor List Called Contact Person
Plumbing �� - •�
Grant Decd Plans picked up
5.1 M.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:. Review, ready for correctio issue
Developer Impact Fee
Planning Approval Called Contact person _
_ _ 3® A.LP.P.
Pub. Wks. Appr Date o[permiI issue
_ 160`1
School Fees � � _ Slia
/( Total Permit Fees
��'iWk`�` i � � fz 3a •a3
To: Greg Butler, Building & Safety Manager To CDD: 11-06-2003
From: Oscar Orci, Planning Manager Due date: 11-13-2003
Status: 1ST review
Building Plans Approval
(This is an approval to issue a Building Permit)
A
The Community Development Department has reviewed the Building Plans for
the following project:
Description: REMOVE/ADD NON BEARING PARTIITION WALLS, RELIGHT,
PAINT, RECARPET, ADD AND RELOCATE CABINETS
* N67E - 418 �0`E�lo R. Aoo,2/ �UiNDet� C'1h4�6�`.�
Address or general location: 78-467 HIGHWAY 111
Applicant Contact: JOHN PETERS (559) 905-2276
The C munity Development Department finds that:
...these Building Plans do not require Community Development
Department approval.
❑ ...these Building Plans are approved by the Community Development
Department.
❑ ...these Building Plans require corrections. Please forward a copy of the
attached corrections to the applicant. When the corrections are made
please return them to the Community Development Department for
review. ,.
• / f♦ 0.Sy(
69'
car Orci, Planning Manager _•ate:;;
• l L
MAR -31-04 WED 9:56 AM RIV, CO, FIRE P&E INDIO FAX VO, 1 760 863 7072 P. 1
Tom Tisdale
Fire -Chief
Proudly serving the
Unincorporated
Areas of Riverside
County and the
Cities or:
Baming
4?
Bcaunloot
Calimcsa
v
Canyon I xgA.e
Coachella
Desert Fled sprinps
lrldian Wells
Indio
ti
Lake Elsinore
La (Uinta
Moreno Valley
e.
Palm Desert
-S
Perris
Rancho Mirage
4 -
San
San Jacinto
�t
Temecula
Board ol'Suporvisors
Bob Buster,
nislriG I
John'ravaolionc,
Jim venshlc,
C>isU ict 3
Ray Wilson,
Ngtricl 4
Marion Ashley,
. I)i;lripl S
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forest �y and Fire Protection
_____270 West San JacinFo Avenue • ems, Califbm=0 • 909) 9 Fax 9) 94
March 31, 2004
City of La Quinta
Building Department
Re: Fire and Life Safety Clearance
The Riverside County Fire Department is,granting_a fire and life safety clearance
for the following project located at,78-467-hwy I_l_l.,_La Quinta. Please call if you
should have and Questions.
41 .
Respectfully
FRANK KAWASAKI
Chief Fire Department
By. � � u.."
Terry DeSoucy
Fire Safety Inspector
EMERGENCY SERVICES DIVISION - PLANNING SECTION - INDIO ornCE
62-575 Hlyhway lit, 2n° Fl., Indio, CA 02201 .-(760) 863-8986 6 Fax (760) 863-7072
Tom Tisdale
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Cities of:
Banning .
Beaumont
0
Calimesa
Canyon Lake
Coachella
Desert Hot Springs
Indian Wells
Indio
lee
Lake Elsinore
La Quinta `
Moreno Valley
Palm Desert
Penis
. s•
Rancho Mirage
4
San Jacinto
Temecula'
Board of Supervisors
Bob Buster,
District t
John Tavaglione,
District 2
Jim Venable,
District 3
Roy Wilson,
District 4
Marion Ashley
District S
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
82-675 Highway 111, 2^a Fi., Indio, CA 92201 . (760) 863-8886 . Fax (760) 863-7072
November 26, 2003
Michael Hurst
78-080 Calle Estado, Ste. 203
La Quinta, CA 92253
Re: . Non -Structural Building.T-A-Plan,Review---,
LAQ-03-TI-096 / Back Pain Institute ,
Fire Department personnel have reviewed and approved the plans you submitted for the above
referenced project. Please be advised the following conditions apply as a part of the conditions for the
issuance of a building permit.
1,) Fire Department approval is based upon the 2001 CBC requirements for Group B occupancies. It is
prohibited to use, process or store any materials in the occupancy that would classify it as a Group
H.occupancy per Sec. 307 of the 2001 CBC.
2) All egress doors shall comply with CBC Sec. 1003.3.1.8 for proper door hardware.
3) Install portable fire extinguishers per Title 19, but not less than 2A1 OBC in rating. Contact certified
extinguisher company for proper placement of equipment.
4) Approved building address shall be placed in such a position as to be plainly visible and legible from
the street and rear access if applicable. In multi -tenant buildings, businesses shall post the
business name and suite number on back doors as well as the front. Suite numbers or letters must
be a minimum of 6" in height. All addressing must be legible and of a contrasting color with the
background.
5) Approval of these plans does not include approval for the volun a fire alarm system. The installing
C-10 contractor shall submit plans to the Fire Department for review and approval prior to
installation.
Please contact the Fire Department Planning & Engineering staff for final inspection prior to occupancy.
All questions regarding the meaning of these conditions should be referred to the Fire Department
Planning & Engineering staff at (760) 863-8886.
Sincerely,
FRANK KAWASAKI
Chief Fire Department Planner
By
Walter Brandes
Fire Safety Specialist
City=of:La Quinta = Buildingng Dept
K.VUWP omua 0*ftft0J WMTiuiaosn.oee.dW
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2^a FI., Indio, CA 92201 • (760) 863886 • Fax (760) 8637072
r
SIP Engineering
•
Co`nsultan.ts, LLC
4-1-04
David Taylor
Pacific Crest Mortgage
68100 Ramon Rd Suite C-9
Cathedral City, CA 92234
14712 SW Scholls Ferry Rd
# 328
Beaverton, OR 97007
503-524-8268
503-213-6222 (fax)
RE: Structural Observation of House at 53440 Avenida Villa, La Quinta, Ca
David,
The horizontal straps above and below the front window appear to be
installed properly on the inside and outside face.
AA
Mike Nelson, PE
•
;SPECIAL
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE UCT. STEEL ASSEMBLY_��_ O ������ *_p
❑ POST TENSIONED CONCRETE O ASPHALT HER
❑ REINFORCED MASONRY O FIRE PROOFING �l�j�✓
JOB LOCATION'ely
LA Q�� �.
REPORT SEOUENCE NO.
T E OF STRUCTURE
1 -� /_ p p -f
PERMIT NO.
b
DAY OF WEEK
MATERIAL DESCRIPTION 11•►\ ^ `
11p-
AR 1
IZLPJ R
HRS. CHARGED
L- _� � �
/
- � C.d4 ��
EN I EEpR`._ �.�'l" •' �
",•-•�
ASSISTANTS
HRS. CHARGED
INSPECTION
- DATE
GENERAL t_ A u ��( U�_tie--CONTRACTOR
- --- CONTRACTOR .0 (� L Cy✓`2 e ��� l (-- - - - - --- -
3 (�
O SEQLL-IK!�1 SI tl IIc- (. RLZIN
&ASe PIA
4x
Q,Q�D OA to1�
(oa-
COPY SENT TO CLIENT ❑
CONTINU ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
'HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
S GNAT �GIo
F REGISTERED INS CT 1? _) !^_
ATE O EPORT �REGISTER NUMMRFR
i
Coil Certificate of Occupan'CY
11 C (far
i I 1 1 TED
C OF't1Building& Safet D
y epartment
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: 78-467 Highway 111
Use classification: Commercial "Back Pain Institute" TI Building Permit li 0311-208
Occupancy Group: B Type of Construction: VN Land Use Zone: CR
Owner of Building: M & H Property Management LLC Address: 12555 Hirth Bluff Dr Ste 285
Temporary Certificate of Occupancy 30 Days City, ST, ZIP: San Diego, CA 92253
By: Daniel P. Crawford Jr.
Date: 4/1/04. Expires 5/1/04
Building Official
POST IN A CONSPICUOUS PLACE