0110-247 (RC)`K LICENSED CONTRACTOR DECLARATION
IIhereby affirm under penalty of perjury that I am licensed under provisions of
6hapter 9•(coriimencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force arid effect.
License # Lic. Class Exp. Date
742112 a C5 11X3010°11
bate it
�• f�'/f Signature of
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that,l 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).
O I am exempt under Section B&P.C. for this -reason
Date Wl &4'1 Signature of Owners !' ,c
WORKER'S COMPENSATION
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.
( )11'�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 11TATO MID Policy No. 046-0-00MIS
(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.
rl r+ • A-1;-+
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 property for inspection purposes.
—•Signature.•(Owner/Agentt ✓,FF Datejj� 2,
BUILDING PERMIT PERMIT#
DAWl Ct1,Ai3-�;�7 `
td,�U,V� VALUATION_`�D LOT TRACT
JOB SITE .ADDRESS M%."47".Mc c��a.i APN -
OWNER CONTRACTOR/DESIGNER/EN (NEER
IBM L&C
1500 112M .A flNUEe
1i,7:ir` WAI
USE OF PERMIT
C1111O.W MC: U, REMODEL
VALUATION
DOUG WALL CrJNSTRUM110K WC.
78-450 AVENUE 41
WA. 19180TI I'MI �2o�Y..iS'JAMCA 92201
Q60)?72-8446 CBIA 5556
MUM&M COW 09'' CO.MINTMION
22,000AYJ
I'.L I'Q4 C.HWK I: E
101.000-439-318
C0143'IRUCT1014, X
1.01-000-4185=000
i� 3.afii
IMECHWC,A>:I:oYES?
'101-U00-421:-000--
$64,00
xELW'7'E .I.CAJ> IWJW
10.1 ••C> .)o -4S C3- 001
$5a.93
21� ;7IV1 I11 4 FEE
10"1'--600.419-000
$4100
'STR0NO MOTION .E. CMM
1 �6-000-241-000
$d.vu
OCT 2 9 2001 L
WY OF LA QUINTA
h1 E�,� 70 �JA>Y 1�,RD PLA)i � C .C: K
VIA , k1lMr.9,' »`i. E s DUE NOW
RECEIPT I DATE BY I DATE FINALED I INSPECTOR
$592.93
0,00
'lA'I -93
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
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 JI -4- O (.
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:.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit -
Rough Wiring . O!
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Tom Tisdale
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Cities of.
Banning
Beaumont
. .;.
Cahmesa
4.
Canyon Lake
4.
Coachella
4.
Desert Hot Springs
Indian Wells
Indio
Lake Elsinore
La Quinta
Moreno Valley
4.
Palm Desert
4.
Perris
4.
Rancho Mirage
s:.
San Jacinto
4.
Temecula
Board of Supervisors
Bob Buster,
District 1
John Tavaglione,
District 2
Jim Venable,
District 3
Roy Wilson,
District 4
Tom Mullen,
District 5
RIVERSIDE COUNTY FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
210 West San Jacinto Avenue • Penis, California 92570 • ) ax ) 1
November 6, 2001
Sipovac Construction
72-651 Theodora Ln.
Palm Desert, CA 92260
Re: Non -Structural Building TA Plan Review
LAQ-0I-BLDG-065 / Pinnacle Diet Center
Fire Department personnel have completed a review of the plans you submitted for the above
referenced project and have no conditions or corrections to be met prior to. issuance of building permit.
1) 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 card must be at the job site for all inspections.
2) Install Knox Key Lock box Model 3200 mounted per recommended standard of the Knox Company.
Special forms are available from 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
require "tamper" monitoring.
3) Install portable fire extinguishers per NFPA, Pamphlet #10, but not less than 2A10BC 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. Minimum of 6" 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 contrasting color with the background.
Please contact the Fire Department Planning & Engineering staff for final inspection prior to occupancy.
Requests for inspections are to be made at least 24 hours in advance and may be arranged by calling
(760) 863-8886.
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
�Chi(eff Fire Department Planner
By ka
Walter Brandes
Fire Safety Specialist
H. W E2WPDATA%LAMIHTAIPROJECTMBLDf)_PCUA?B1-B LDO-OBS.doc
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2^d FI., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072
EXHIBIT A Permit # 0110-247
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.
C / e
Agreed to and Accepted by:
Date I