0106-109 (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, andmyLicense is in full force and effect.
License # Lic. Class Exp. Date
f
B. 7!
Date .f -'-" : Signature of Contractor '
�rsaaT
OWNER -BUILDER DECLA
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).
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.
t ( �)•, 1 have and will maintain workers' compensation insurance, as required by
Sd"ction 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.
FUND i 9�;EG�d tfg
(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 with those provisions.
Date: Applicant `i__ . .5 i f I
%
Warning: Failure to secure Workers' Compensation coverafe is unlawful and
shall subject an employer to criminal penalties and civil fine's up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions 'set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La' Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance cf such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct: I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property
ufor , inspection pTPO
ses.
.Signature-(Owner./Agent),
? ��.<.'$Date^ rl;
BUILDING PERMIT PERMIT #
DATE VALUATION LOT�.ufp �Y� TRACT
JOB SITE
APN ^
ADDRESS 010
/f.�"'"o:l�.w..B,dAx.YJ::d.V'1'DtA•.A .�l �. R: S J ♦ ` �i � Z
•. •.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
102 S, 3UHRIM WAY
621 LIUVAR.AVEITUE?
1%d33: '1121 1�4 f"�l 92262
t;',1�yl�j92821
1�iaytiyt��db
�f fCty y
_ C1 I�`S.)Z5! J-�E[��00 `v3.` 4
USE OF PERMIT
`k'bfii,&V P TNP§WXeMKHT PER APb ROV11,'33 PLANS �5�,` 5 //1 0- Y, e- T)
i •
AINIT"D COST OF CONSINUCTION
WIT
CONUTRiJ4."'i ION FES. 101. -000.418-000 n,00.10
F'l..ar4W Cl•3"FCK RE 101.000-4.1941.9 $3,419.!3`x'
19112 DEPWIT 1111.-0100-439-3121 41,500,90
Y CRAM I+C.'AE, f e,:i?
1,M,TR1.CA, 1sFR8, tCD1 t70 4 U i?C1PD 4�,i.��
P3,,3JIt iPO=f Gftot 11114*10-4 9-000
�
S
O
2001�H,ug
AU;4—
a
&4721
e. ar�.-RA, QW FM
4),5500,00
RECEIPT
DATEBY
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 �o•� �� O ( �,K
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
POOLS - SPAS
BLOCKWALL APPROVALS
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 �j - (
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection"�-� �"
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�'4 1� v►^ 3
• Z �� V 1
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) p • 2 Cl( �f/
City of La Quinta
Developers Project Approval Form
Prior to the issuance of Certificate of Occupany for the project listed below, the following
Departmental clearances must be obtained. Please. return this form to the Building and Safety
Department only after approval. Contact applicant for resolution of conditions preventing or
delaying approval.
Project: JENSENS TI
Applicant Contact: PATRICIA GEE 626-793-9119
o
Application / Circulation Date: 12/13/2001
Date
Community Development Department
r
Christine Di Iorio, Planning Manager Date
Public Works Department
n .o,
Steve Speer; Senior
Building and Safety Department
Greg Butler, Building and Safety Department Manager
Health Department
Fire Department
Date
Date
Date
Date
r
v City Of La'Quinta
Developers Project Approval Form
'Prior to the issuance of Certificate of Occupany for the project listed below, the following
Departmental clearances must be obtained. Please return this form to the Building and Safety
Department only after approval. Contact applicant for resolution of conditions preventing or
delaying approval.,
Project:. JENSENS TI
Applicant Contact: PATRICIA GEE 626-793-9119
Application /Circulation Date: 12/13/2001
Date
Comnity Development Department
L
Christ e Di Iorio, Planning Manager Date'
Public Works Department
Steve Speer, Senior Engineer
Building and Safety Department
Date
Greg Butler, Building and Safety Department Manager Date
Health Department
Date
Fire Department
Date
EXHIBIT A Permit # OI O
NOTICE: THIS IS ONLY A TEMPORARY PERMIT. THIS
PERMIT WILL EXPIRE IN 30 DAYS. IN ORDER TO
CONTINUE OCCUPANCY BEYOND THAT DATE, OWNER IS
REQUIRED TO OBTAIN 'A FURTHER OCCUPANCY PERMIT.
BE ADVISED THAT NO PERMANENT OCCUPANCY PERMIT
WILL BE ISSUED UNLESS AND UNTIL OWNER HAS
COMPLIED WITH ALL REQUIREMENTS NECESSARY TO
' RECORD THE FINAL PARCEL MAP NO. 29791 AND THE
MAP HAS , BEEN RECORDED, AND ALL -OTHER
CONDITIONS OF APPROVAL HAVE BEEN MET. WHEN
THIS PERMIT EXPIRES, ' THE OCCUPATION OF THE
BUILDING SHALL CEASE AND ALL OCCUPANTS SHALL
VACATE THE BUILDING UNTIL AND UNLESS A FURTHER
OCCUPATION PERMIT IS OBTAINED. OWNER AND
OCCUPANTS AGREE TO AND ACCEPT THIS RESTRICTION
IN ORDER TO OBTAIN THIS TEMPORARY PERMIT.
Agreed to and Accepted by: X
Date
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: 78-525 HIGHWAY 111, SUITE 200
Use Classification: COMMERCIAL Bldg. Permit No.:
Occupancy Group: M Type of Construction: V-1 Land Use Zone:
Owner of Building: ADAM ZACK
Building Official
0106-109
C�3
Address: 102 S. SUNRISE WAY
City: PALM SPRINGS, CA 92262
By: RICHARD KIRKLAND
Date: APRIL 4. 2002
POST IN A CONSPICUOUS PLACE
`Certificate ''of Occupancy
City of La Quinta,4
Building and Safety Department OfTM
This Certificate issued pursuant #o 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: 78-525 HIGHWAY 111,- SUITE 200
Use Classification: COMMERCIAL - JENSEN'S FINEST FOODS
Occupancy Group: M Type of Construction: V-1
Owner of Building: ADAM ZACK
TEMPORARY CERTIFICATE OF OCCUPANCY
SEE EXHIBIT A, ATTACHED
Building Official
Bldg. Permit No.: 0106-109
Land Use Zone: CR
Address: 102 S. SUNRISE WAY
City: PALM SPRINGS, CA 92262
By. RICHARD KIRKLAND
Date: 12/19/01 EXP. 03/15/02
G
I POST IN A CONSPICUOUS PLACE I
SEE EXHIBIT A attached
f . + '' ti .� ,1' Jh' r 2' r
1 i t t ! I.e k o �T _ Iy4: v t ,
1,r
C,
(;Itv of La Quinta
Building and Safety Department O'F
This Certificate issued pursuant to the requirements of Section 109 of the (Inform 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: 78-525 HIGHWAY 1 1 1 SUITE 200
Use Classification: COMMERCIAL Bldg. Permit No.: 0106-109
Occupancy Group: M Type of Construction: V-1 Land Use Zone: CR
TEMPORARY CERTIFICATE OF OCCUPANCY
Owner of Building: ADAM ZACK
Building Official
Address: 102 S. SUNRISE WAY
City: PALM SPRINGS CA 92262
By: KIRK KIRKLAND
Date: 12-13-2001 EXPIRES 01-13-2002
POST IN A CONSPICUOUS PLACE