0107-316 (PLBG)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. ClassM fExp. Date
G °bate "/ M '' f Signature of Contrac or-
,ell
r-
OWNER -BUILDER DECLARATION e
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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:
c) 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.
*STAU FUND 161$2W01
(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 inrany manner so as to become subject to the
workers' compensation laws of California, and agree thatjif I should become
subject to the workers' compensat�n provisions of Se'c`tion 3700 of the. Labor
Code"l-shall forthwith comply with those 1101 Igns
(Dat
e: APPILcant
Warning: Failure to secure Workers' Compensation coverage Lanlawful 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 a
whose request and for whose benefit work is performed under or pursuant t Rj
any permit issued as a result of this applicaton agrees to, & shall, indemni j II f
& hold harmless the City of La Quinta, its officers, agents and employees311
2. Any permit issued as a result of this application becomes null and void.J y' '
work is not commenced within 180 .days from date of -issuance of SUCH- f
permit, or cessation of work for 180 days will subject permit to cancellations
I certify that I have read this application and state that the above information is
correct. I agree to comply with "" II City, and State laws relating to the buildin pppI
construction, and hereby authoTize representativespof this City to enter upon
the above-mentioned property for inspection purposes.
�daf�. f'
Signature (Owner/Agent)�"� �� Date��
BUILDING
PERMIT PERMT#
DATE VALUATION
LOT (JJ0?_' TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
G.J. IkiZY1Z?�i'x L^�.I3�:?t �C�.�'C',�3,EV
311
72,764.19MCAd&DA.
LA fa'(' ,11rVA
CA, 92253
PALM X .9M. — °r C& 92260
(160)340-9423 CSLA
OfA30
USE OF PERMIT
.4"1TAK I WASTE' 1,1118 i1't�9, Bt9lLOIN 0 94 SfUi TES A & 8. Q
VALUATION
1119
1901 -D COW OF CCIARFRITC," I(XIT
_700M)
€' IS�`'` f"sfiVA&WJo CY
''E11R,finn
qq
JU L 3 1.2001 (. g
1XIMs P.rKEW11� 8 WE NOW
U1,130
L„ d
Cli'i' OF LA OUINIA
_ iNANCE 001'
/
RECEIPT
DATE, ]{
BY (\ %
DATE FINALED
INSPECTOR
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 APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
-
_
NOV-21-01 WED 9:55 AM . RIV, CO, FIRE P&E INDIO
Tom Tisdale
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Cities of:
Denning
Beaumont
4
Calimesa f
Canyon Take
Coachella
v
Desert Hot Springs
r,
Indian Wells
hidio
00
Dake Elsinore
4.
1A Quinta
Moreno Valley
00
Palm Desert
0
Perris
0
Rancho Mirage .
..y
San Jacinto
0
Temecula
Board of Supervisors
Bob Duda,
Disvia 1
John Tays6onc,
AM Vcnable,
DWid 3
Roy Wilsorw,
District 4
Tam 1.4ulivn,
DiDtricA 3
,
FAX N0, 1 760 863 7072
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
C761ijornia Department of forestry and .Mre Protection
es an Jacinto Avenue • Perris, Califomia 9Z10 • • Fox (9m) 94&6910
November 21, 2001 dLe
City of La Quanta
Building Deparunent
Re: Fire and Life Safety Clearance
?r- 30v
The Riverside County Fire Department is granting a fire and life safety clearance for the
occupancy of Pacific Dental.
Respectfully,
FRANK KAWASAKI
Chief Fire Department Planner
By Terry DeSoucy
Fire Safety Inspector
EMERGENCY SERVICES DIVISION 0 PLANNING SECTION • INDIO OFFICE