0206-215 (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
P ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
� y
88921111 D Inc 05 1/2(
,,,-Date� Signature of Contractor^- a
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 gT,.k & FLrk_4D Policy No. QUOTE 05101 W
(This section need Knot 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 th se provisions.
'Date: -11 Z �' i u 2 Applicant—
Warning:
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 propertfor inspection purposes. ^�
'Signature (Owner/Agent) � � `" � Date 1 'r:5 Q � `
PERMIT PERM T#
/J (BUILDING
DATE J� / VALUATION T LOT"'- TRACT
JOB SITE
ADDRESS 78-474 � .a WAY II I =X C.
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
t+ ADW OW Dr:V.)TTk/9N d
ASA.Ro 1-MILID��S
938 14.iA OU ARM AVRNi.M
PO 3.3QX '3
ONTAR10 CA 9?762
RANCHO 1HANT.A. FE CA 92.967
USE OF PERMIT
is (3MMFIi-0iE'.L IZE-M DEL
` ENA11 T IMPROVEMENT 4 1537 S.F. 'S' ClCt;ti.I ANCY. T't'P.K'V-N
SPEtl114KI !. ED (tel CHIROPRACTIC)
C014 t RAC T AMfl(,iNT 1011 L '
..L`vIRa..Ld`AAM C05.r OP CUI G9x��4�Y. S,:� 701V
-
2011 10100
SEER-Mri'�.� E J. - - .
+COINSa:RUCT?ON R, 101.000.418.000 SM00
PLAN tW,`I-W.4,t: PEE $2x2.84
CHANICAL F U 101-000421;-00,C] $119A
7 I..WTRICAL ME 101-060-420-000 M:Ff:.t
Pi.;t;M01.14t3FEV 101-OM419-000 W.50
STRONvCI MOTION 1W, — COMIM 100-000-241 iTOQ FAX
.z
z° L O£'�1�'St'� C.110H �A1 F�2,.h' N CM1."`l�'
$6231.51
�UUM.i/
Sr�ESS �.R.I�o=i�Ai. i ,SKI
ZOO
A�.9's�lt�L' TTMI ' �,r3slCi' E IgIO Y
JA
96aUv� it,T�)
JUL 2
CITY OF LA QUINTA
FINANCE®EPT .
RECEIPT DATE / By /, DAT F INSPECT
-
r
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
QQj _
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 PIN. Test
Final
I
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 A_
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
JW221
02 02:08p
04/22/2002 13:34
Bin #
Prest Vuksic Architects
7607777011 LA DUINTA
Permit M
Project Address 5 `')
A. P Number:
71 Contractor: A5
Address:
60
Cite, ST, Zip: P
Telephone:
� —60-1
Statc Lic X:
Arch, Engr..
Designer.
Address:
oz J js.
City. ST, zip: DR M
Telephone:
% 7.1--q
State Loc. g
C tcf 71L
Namc of Contact Prrson
Telephone a of Contact Person
p Submittq
Plan Sets
Structural Calcs.
Truss Celts.
Tltle la Calcs.
Flood plain plan
Grading plan
Subcentactor List
Grant Deed
H.O.A. Approval
114 HOUs1Er.
Planning Approval
Pub. Wks. Appr
School Fees
bulC
(760) 779-5395 p.2
PAGE 02/02
City of La Quinta
8(diding far Salery bhticin
P.O. Box 1504, 78.49S title Tampico
La Ouinta, GA 92253 • (760) 777.7012
Building Permit Application and Tracking Sheet
f Owner's Name: M i C k ctc I_ QC4w y) Y1 A�
Address: �g
cit,.ST. Zip:
)�Cl L) cA_ 112.z0I �
IT- (A 92.2C,G
City Lic. a: ~
�►�ic-PtzPsr-Uu sf tom`'
,3410 Sri ItGI
Z 2 I 1
Telephone: (
Project Description: 9 ,
-S occG ATi G
C�tfz��ac-f�G
Construction Type: Occupancy:
Project tppe (circle one). New Add'n Alter Repair Demo
U u j l L Sq Ft.- rr Storics: a Units:
Estimated Veluc of project 70, ocro CCS
APPLICANT: DO NOT WRITE BELOW THIS LINERaw—
Re<'d I Tq s[w twrr
*AD � P1311 Cheek submitted
peebn, i(r Revlewed, ready for corrections
Called Contact Person
Plane picked up
Plans resubmitted
2"' Review. ready for correction
Called Contact Person
Plans picked up
Plans resubmitted
Review, ready for correction ,
Called Contact Person
Date of permit issue
q T rN J - �izcs� V -t> .-.
PERMIT FEES
Item
Plan Check Deposit
Plan Check Balance
Construction
Mechanical
Electrical
Plumbing
s.l►Li.
Grading
Developer Impact Fee
A.t.P.P.
Amount
1 Total Permit Fcrs L
��21Io2 - 0W TO 155JE
ApPevrA(l
zze vrc.�y
-S� 7?—
O/C
?'ati i
Tom Tisdale
Fire Chief
Proudly serving the
Unincorporated
Areas of Riverside
County and the
Cities of:
Banning
Beaumont
Calimesa
4 -
Canyon Lake
.;.
Coachella
Desert Hot Springs
Indian Wells
4.
Indio
Lake Elsinore
4.
La Quinta
4.
Moreno Valley
.;.
Palm Desert
-.1-
Penis
4.
Rancho Mirage
4.
San Jacinto
.;.
Temecula
Board of Supervisors
Bob Buster,
District 1
John Tavaglione,
District 2
Tun Venable,
District 3
Roy Wilson,
District 4
Tom Mullen,
District 5
,PA-6�L Scow POC
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
210 West San Jacinto Avenue • Perris, California 925 0. (909) 940-9000 • Fax (909) 940-6910
July 22, 2002
Fire Department personnel have completed a review of the plans you summated for the
Above referenced project. Please be advised the following conditions apply as a part of
the issuance of building permit.
Fire Department approval is based upon 1997 UBC 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 1997 UBC.
Fire Sprinkler system plans for the tenant improvement area must be submitted to the Fire
Department for review, along with a plan/inspection fee. The approved plans, with Fire
Department job cards must be at the job site for all inspections. ,
Install Knox key Lock boxes, Models 4400,3200, or 1300, mounted per recommended
standard of the Knox Company. Plans must be summated to the Fire Department for
Approval of mounting location/position and operating standard. Special forms are
available form this office for the ordering of the Key Switch, this form must be
authorized and signed by this office for the correctly coded system to be purchased.
If the building/facility is protected with a fire alarm system or burglar alarm system, the
lock boxes will required "tamper" monitoring.
If the facility requires Hazardous Materials Reporting (Material Safety Data sheets) the
Knox Hazmat Data and key Storage Cabinet, Model 1220 or 1300 with tamper switches
Shall be used. If the building/facility is protected with a alarm system or burglar alarm
System, the lock boxes will require "tamper" monitoring.
Certain designed areas will required to be maintained as fires lanes.
Install portable fire extinguisher's per NFPA, Pamplet #10, but not less than 2A10BC in
rating Contact certified extinguisher company for proper placement of equipment.
Shelving, counters, ect. must be in place, however, no merchandise may be placed in the
Building prior to the inspection.
All fire sprinkler system, fixed fire suppression system and alarm plans must be
submitted separately for approval prior to construction. Subcontractors should contact
The Planning & Engineering office for submittal requirements.
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
RIVERSIDE COUNTY FIRE DEPARTMENT
FIRE PROTECTION
JOB CARD
THIS INSPECTION RECORD MUST BE
AT JOB SITE WITH AN APPROVED
SET OF PLANS
Owner Ch- Date
8 i of
I - �-- -_
Case No. Ll�Q-oz
-
•!�3
= �-
Sprinkler Company
j
Underground Static Date
(200 PSI For 2 Hrs. Prior to Inspection
Time).Inspector
(Center Load Pipe Only, Joints and' Thrust
Blocks Must
Be Exposed)..
Underground Flush
Date .
Inspector
PaQ
Ov hea Static
Date
(
Inspector
e)
S
7as''ZI
n
Overhead Final
Dat
Inspector
Fire Main Installer
Underground Static Date
(200 PSI For 2 Hrs. Prior to I pection Timej Inspector
(Center Load Pipe Only, J ' is and Thrust Blocks Must Be Exposed).
Undergroun lush Date
Inspector
05 30/2002 19:41 FAX 7609212222
"`�c�icnnl 10:22 13103051492
WY 29 '62 09:45gM MEDZCRL
by
Jamb MOM
Roemgea Medical X-RAY Co.
12921 Washington Blvd.
Los Angelea, California 90066
DR Chiropractic Inc.
RMXC
mmics
Way 29.2002
Q004
PAGE 02
P.2/5
RE: Protec6ve Barrier Ri === ns fora new.x-ay room to be located at D R CbitoW=tic,
78474 Highway 111, Safte C, L.a gym. CalifCia 92253.
Dcar Mr_ 8liafan:
The following report formally defines the conditions and assumPtiona for the shi
the prioposed installation. CRs for
Protective battier MoganjevAwou are based on ctitada
Sh(ald:et t thin Nt3+tP S
ta8Dastgrs and 5valuation forMediaa! Use X - Rays RAPon No. 49: tt amunl
Mery sad tb California Radiation Castrol 'mad -Rays �FrrerBitJ Up 7'o 10
Ragubliom. Mde 17, 1980. R=Omnumdations conoemw
�
ttaion of Slab Siris far leaded glass are based on The Useof Plate Glaaa as Shield* A&Wrwl
grrosrie Radiologic Irftuatroru, ". 'Dont, ex al.. JmrxW of the Cam Asumbdm of
RMU0100 ts, VOL 25M pp, 173-77, Sepwmber.1974,
fixpasure to Persoucl and the general •Public was takes into considmation. The coturolled areas we
desig so that the exposum to Personnel will be less than 100 millirem per week, and the a to
Uncvnhvlled •areae less ban 2 miUir
te�tti per week,
The f0U0W ng is a list of assomptions which apply to the factiabove. ity noted if my of these
not valid, Please iafmm me, 5inoe my recotamendations may differ for diffae:nt
cirmamatances_
it is aasncned *AL.
1. the pcopascd facility is located u: .
X,Ray Room
DRChuairacdc
78474 Highway 111, Suite C
La Qaint4 California 92293
Z. all Primary and secondary barrim, Unkm odmrwise
above the floor of rive x-is3' loom: shad and to a height
of at least 61;
.O, Box 24687, l.os Angeles, Cagfomla pCO24
(818)-SmLsi
*15/,90/2002 19:42 FAX 7609212222 DR Chiropractic Inc. 0 005
`5/29/2002 10:22 13103051492 RNM
MAY 29 W 89:46AM PUICAL pHySICS PAGE 83
8ruce A. Ham Meditad PhysIcUt P. 35
-CertMd by u% Ameftm Boma of RaQloloW in 01agnoalia Radol991cW PTWSN= and
Medt" Nudaar Phystm
3. all holes in barnun for pipes, caMduits, and louvers shall be provided with baffles so that the radiattoa
Witted throu.4 them does not exceed that aaasmided dmmgh the
and doors shall offer the same degree of amm=602 as that 3UMMnditlg ba km- windows
locared. re4Wed of the barrier ih whish they am
4• any joiner between diffee t protective barriers shall
thicket bartier overlay at least as gleet as the liridraess of the
S_ all inm'or walls, ualeas othatarise stated, at! covered as both sides with a mutirnuizi SB" thick
gypsum board;
6, the equipment to be b malled conforms to the pettmeat metal regulation as stated m the
California Radiation Control Reguladcas, Title 17, and tba Radiation Cartrol for )iealtb and Saf
Act of 1968ety
.
SPoc3tliie 'k"'nPU0W (Sec I~igum l)
It is assumed that
1 • ma�uru*o �h (W) in any Cue .geek shall be hese tbao 75 mil '
mutes far
2. the maximum tube potential of the x -fay unit Is 12$ kVp: the avrtggt tube potmntia:i for secondary►
harries design is 100 kVp;
I the Proposed faeil9ty is Iccated in a Angle -level building;
4. the o=upa=y factors, primary barrier use factors, avM& 4jbe pow used for
pi
design. dssign.dose level, and type of area are presented in the fclloav 09 table for each arrkt;
Barrier
A
Arra
Controlled
Desitin
Dose
—k
Occupancy Use Phmaly
Factor Factor Tube Potted
0,1 m
B
UnMtwBad
0.002 remfwk
1/16
C
Uncontrolled
0.002 tetn/wk
1/16 1
D
Uncontrolled
0,002 temhvk
100 kVp
1/16
1?
Uncontrolled
0.002 iem/wk
1
F
Undonerolled
0.002 Mm/Wk
1/4 -
G
UncontmIled
0.002 remfwk
1/16 -
H
ContzvQed
0.1 MWLWk
1
P.O. Box 24587, Loo Angelos, California
(87 8)S02 -S
V'5/30/2002 19:42 -FAX 7609212222. DR Chiropractic Inc.
. . -_ i.3insn51492
MAY 29 '02 09:46AM MEDICAL pH' ICS RhCCC
zoos
PAGE od
-0 6 —a Jowcuu=6324"aw
.111 barriers size shield}ng co a bight of at least 68" above the floor valets WxVWise now.
DA
P
C
E
F
G
Flow
Now
Requited Shielding
1.0 lb✓sgIt lead (1/64"tixck)
1.0lb/sq.ft lead (164" thick)
1.0 lb/sq. t jead (1/64" thick)
No additional shielding requitrd
1-0 lWsq.ft lead (1/64" thick)
1-0 hb/sq.ft lead (1/64" tidck)
No additional shielding tequh-ed
No additional shialdiag required
No additional shielding sequined
>f_ - A— . -- .--
Additional Welding
Behind Wa1b ilr�wiw.
+ 2.5 lb/sq.ft lead (5/128" thi
extead at Mast 1'0" oa esch side.and a ve and bellooww its oraoge of vertical travelmust be centere- -to the Bucky +aod
the obsef"f m window is battier A, Eire ooatrol console battler,
pound Per square foot lead, lead acrylic 12 nun thick, ar Plate glass S�cbh a gl� a 1.0
'lbws protective barriers have bum cotrsar V3d%- 1y, designed so that under norr::n1
as defined in Chia report, no individual is likely to ttteive more tin the air e. Th ion r
load may be substituted if it is mole economical_ If you have pmaplease a cents=
m,B, Tbir�s
Y nay questions, pisses contact nae.
BH:bh
Arrachn=t
P.O. Box 24687, Los
c.airromwa 90024
sincerely,
Bruce Hom
mod" Physicist
r
18}SQ2.6180
.-05•/:'40/2002 19:42 FAX 7609212222 DR Chiropractic Inc.
05129/2002 10:22 13103051492 RmxC
MAY 29 '02 89=46AM MEDICAL PHYSICS
amm—Ov _ jCA\ ` i 1
Q 007
PAGE 05
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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
❑ REINFORCED CONCRETE TRUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE ❑ASPHALT OTHER p�
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JQB 6 - �
CsA u ' �A
REPORT SEQUENCE NO.
TYLE O�STRUCTURE'
PERMIT NO. � —
Dg/j/0
DAY OF WEEK
MATERIAL DESCRIPTION_� /
r/�
A ITE T .S(C
IN
NRS. CHARGED
C_ f T -+g �
ENGINEZ /•
L t/J
1�r
ASSISTANTS'
HRS. CHARGED
INSPECTION GENERALSUB
DATE CONTRACTOR
n 1 ` C �, CONTRACTOR
'r♦�J J
1 �
13
X!Tp-"
�' k «4T-Lp-,�
SfW c,J" c r-►
Cow. 4 -t -a
j�l oII A
D&SS tO
F - P, tcJQA-&t0 I4
-ft— wtoY,3 S(TR—
W-e_
c1J fl x R�
L9 -C' La-
0 W
s
CA
A �S
COPY SENT TO CLIENT O
CONTIN
NEXT GE
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MN
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
URI OF REfrISTER INSPE� A
DATE RE ORTTT REGISTER NUMRFR J
MMIN10--mmoomms
Certificate of Occupancy
City of La. Quinta
Building and Safety Department:
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: 78-474 HIGHWAY 1 1 1 STE C
Use Classification: TENANT IMPROVEMENT (CHIROPRACTIC) Bldg. Permit No.: 0206-215
Occupancy Group: B Type of Construction: VN Land Use Zone: CR
Owner of Building: MADISON DEVELOPMENT
��4n
Building Official
Address:
938 N MOUNTAIN AVE
City:
ONTARIO, CA 91762
By:
DANIEL P. CRAWFORD JR.
Date:
10/28/02
POST IN A CONSPICUOUS PLACE