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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.
Lice, se # Lic. Class Exp. Date
4'5425 C-45 -2 /3alaf
Dat�� Signature of Contractoori :� � �+teA 0 fi
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.f
a)' 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 STATE FUND Policy No. 162207A-2063
(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,,l shall forthwith comply witH,those provisions. �,
Applicant�. • A �h .r„ �, t L 6
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on. his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result"of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation o(work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and, hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) s s a r:� _ eD_ate "a "�
BUILDING. PERMIT
PERMIT#
DATE ��st yf y)3 f a VALUATION 1�Ap ((44PPpp LOT
030'7-2 73TRACT
JOB SITE
ADDRESS
APN
OWNER {
CONTRACTOR/DESIGNER/EN &NEER
ONE ME- VEX I..k QTSW.CA
J:..ORM ET'.M"MOML SIGNS
46-7.533 ADAIG STIRM:L. -
; 7 A.& VCfm J��. i'- F1QPD
x4k QTfkr.'A CA 92251
MONM -1 Lo CA,
9064,4)
(562)946-7545 CBLIf
USE OF PERMIT
ILLUMINATED WALZ, SIGN, 3 CIRCUITA WO a
i
7EMN,aATM CON'r 0'r CONSlNCTION
VER=r FE9,81MMARY
MFICrTUCALFFEV 101--000.420.000
i-1•t�T�T C�J2�i . !T rC� AND P1;A1rGT7w ...
'33.00
U
LESS -PAID FF93
40100
JUL 2.2 200 �� xgry, Fgrv, you Now
x:00
CITY OF LA QUIP9TA .. • . ,
FINANCE DEPT. '
. 4
RECEIPT
DATE
By -.Be
DATE FI ALED
IN$P OR
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
OX 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 a3
BLOCKWALLAPPROVAILS
POOLS -SPAS
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
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 3
Low Voltage Wiring
FbtWres
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 113
Utility Notice (Perm)
COMMENTS:
Y.V. box 15U4
78-495 CALLS TAMPICO (7 6.0) 777-7000'
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-710.1
July 21, 2003
Mrs. Sue Moderegon
SUBJECT: SIGN PERMIT 2003-711 (Big 5).
Dear Mrs. Moderegon:
The Community Development Department has reviewed and approved your
request for a permanent mounted business identification sign at 78-400
Highway 1 1 1 . The approval is subject to the following conditions:
1. This sign permit is. for one permanent illuminated sign with channel
letters. The colors and materials for the sign are per approved plans on
file with the Community Development Department.
2. Obtain a. building permit from the Building & Safety Department prior to
installation of the sign.
I have enclosed an approved copy of the plans for your submittal to the
Building Department. Should you have. any questions or need additional
information, please contact me at (760) 777-7068.
Sincerely,
JERRY HERMAN
COMMUNITY DEVELOPMENT DIRECTOR
MARTIN MAGANA
Associate Planner.
C: B liu ding & Safety Department
Code Compliance. Department
Chron File
4