0111-086 (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
746526 B
f
'DateSignature of Contractor -'u`
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).
( ) 1, 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
ctio
Sen 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 STATE FUND Policy No. Zi9600_2001
{
(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' compensationprovisions of Section 3700 of the Labor
`Code, I shall forthwith comply with f6see4 rov'isions. ,O
Date:. ?� 4-1 Applicant ✓ ��`^y►~ !,' �'"
Warning: Failure to secure Workers' Compensation coverageN.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 persb6,at
whose request and for whose benefit work is performed under or pursuanfto
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 for,inspection purposes,
Signature (Owner/Agent) -� � '9 Cate ? �?
PERMIT #
BUILDING PERMIT
DATE VALUATION $39,2ls�i.% LOT TRACT
JOB SITE
A D D R E 77&.59.5 T-AVY 1x.1 = 100 APN
S
IOWNER
JIM UX,
1500 a 1 MAVE-1,91 : M
MOAQ1:1ATIT
USE OF PERMIT
.Ni'R0EiZM9',+7T (44',10 M
CONTRACTOR/DESIGNER/ENGINEER
OICMOLL F. 3RV.t::l.,CiP. .Q4T
WA 9802? 1. '"RO MAD ck 92357
y9Qi�)?$OKlla3 C"t�U 6640.4
.SIC • COM1i/1FUL&L,
CON'x1i AC T MC2MIT
4,939.00 SF
22,000.00 t)—.4
E. mum1m) Con Cir CI.?i SMUCTION
CONSTRUC:710Ht� B 101-000-4 00-4 0 $3.19,50
f�I_AN CHECX FFIE 101-000. - -318 019.5
NIRCl3" iCAL ME 101-000-411,0M, 8154.130
�e;'.i.3XTt:Bt;.rh,l. MY, ^. '101-000-420.000
I
34,2w".50
0
01
`',/ ® i •� SwSr
RECEIPT DATE ,BY- DA .E IN�A7LED _Q INSPEC
'G
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts _ z
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing — `G.
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 I 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
COMMENTS:
u✓
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)
/Vo it
fi V r tea
V Cz
wl#� QY Of La Quinta
Building at Safety Division -
Permit # P.O. Box 1504, 78-495 Calle Tampico
100 La Quinta, CA 92253 - (760) 777-7012
U Building Permit Application and Tracking Sheet
Project Address:
Owner's N
A. P. Number:
LI Owner's Name:
Address:
Legal Description: City, ST, Zip:
T I
Cont 3nt Telephone:
64"
Address:
e2 Project Description:
City, ST, Zip:
......... .
Tel
&are 'Lc. #
City Lic
Arch., Engr., Designer:
Address:
City. ST, Zip:
Telephone: Slpol_)IC7
State L C
Name of Contact Person:
Telephone # of Contact Person:
# Submittal Req'd
Plan Sets Zold
IV
Structural Calcs.
Truss Calcs.
Title 24 Calcs.
Flood plain plan
Grading plan
Subcontactor List
Grant Deed
H.O.A. Approval
IN HOUSE: -
Planning Approval
Pub. Wks. Appr
School Fees
S
I � VIVA MM =01
o oc /oC49/13>
0 CC' ; 7 V 6 52J
Total Permit Fees
�ft
Construction Type: OccupancN-
Project type (circle one): New Add' n Alter Repair Dcmo
Sq. Ft.: 9
4stories.
4 Units:
•
Estimated Value of Project. 4 0V
APPLICANT: DO NOT WRITE BELOW THIS LINE
Rec'd
TRACKING PERMIT FEES
Plan Check submitted I
112, Item
Amount
Reviewed, ready for corrections
//Ag Plan Check Deposit
Called Contact Person
Plan Check Balance
Plans picked up
ction
Plans resubmitted
echanical
2"' Review, ready for corregiZissue
ectri'.1
Called Contact Person
Plumbing
Plans picked up
SAM. 1.
Plans resubmitted
Grading
Review, ready for correctionslissue
Developer Impact Fef
A.I.P.P.
Called Contact Person
Date of permit issue
b 21111
Total Permit Fees
�ft
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
2tOWest San Jacinto Avenue o Perris, California 92570 • ) Fax ) 6910
Vovember 28, 2001
Tom Tisdale Michael J. Murphy, AIA
Fire Chief 2601 No. Del Rosa Ave, #220
San Bernardino, CA 92404
Proudly serving the
unincorporated Re: Non -Structural Building Plan Review
areas of Riverside LAQ-01-BLDG-087 / Banner Mattress
County and the
Cities of: Fire Department personnel have reviewed and approved the plans you submitted for the above
Banning referenced project. Please be advised the following conditions apply as a part of the conditions for the
issuance of a building permit.
Beaumont
1) Fire sprinkler system plans for the tenant improvement area must be submitted to the Fire
Cahmesa Department for review, along with a plan/inspection fee. The approved plans, with Fire Department
Job card must be at the job site for all inspections.
Canyon Lake
2) Provide either a separate Knox Key Lock box, Model 4400, 3200 or 1300, mounted per
Coachella recommended standard of the Knox Company or provide key(s) for inclusion in the general building
Desert Hot Springs Knox Box. If the building/facility is protected with a fire alarm system or burglar alarm system, the lock
boxes will require "tamper" monitoring. Special forms are available from this office for the ordering of
Indian Wells the Knox Box, this form must be authorized and signed by this office for the correctly coded system to
be purchased.
Indio
❖ 3) All egress doors shall comply with CBC Sec. 1003.3.1.8 for proper door hardware.
Lake Elsinore
4). Install portable fire extinguishers per NFPA, Pamphlet #10, but not less than 2A1 OBC in rating.
La Quints Contact certified extinguisher company for proper placement of equipment.
ev
Moreno Valley 5) Approved building address shall be placed in such a position as to be plainly visible and legible from
Palm Desert the street and rear access if applicable. Building address numbers shall be a minimum of 12" for
4. building(s) up to 25' in height, and 24" in height for building(s) exceeding 25' in height. Minimum of 6"
Perris lettering is required for suite identification. In strip centers, businesses shall post the business name
❖ and suite number on back doors as well as the front. All addressing must be legible and of a
Rancho Mirage contrasting color with the background.
San Jacinto Please contact the Fire Department Planning & Engineering staff for final inspection prior to occupancy.
Temecula All questions regarding the meaning of these conditions should be referred to the Fire Department
Planning & Engineering staff at (760) 863-8886.
Board of Supervisors
Sincerely,
Bob Buster,
District 1 FRANK KAWASAKI
John Tavaghone, Chief Fire Department Planner
District 2
Jun Venable,
District 3
Roy Wilson By ~
District a Walter Brandes
Fire Safety Specialist
Tom Mullen,
District 5 HME2wPDATAUAQUINTAXPROJECTS%TN_IMPRV""I-BLDGN7.doc
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2nd R., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072