9808-118 (CSCS)LICENSED CONTRACTOR DECLARATION
I hereby affirm tinder 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
1 5264E+ F CC! /11/00
752648
Date ��' 1� `�P� Signature of Co to racfoarF�L.�1--.,
_OWNER-BUILERrDECLARATION
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 ISignature 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
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.
STATE- FUN,0
(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` comp nsation•provisions ojaS ctlon 3700 of the Labor
Code, I shall forthwith comply wit�"(those•pro`Vislonts�
Date:/6 /=' Appliicant1i..
'Warning: Failure Failure to secure Workers' Compensation coverage is'unlawfUl and
shall subject an employer to criminal'penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
F'' 1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction; -and hereby authorize representatives of this City to enter upon
the above-mentioned prope y'f, r ins ection purposes. 1
Signature `(Ow,n�er/l eent�» -�+ -- _ Dafe r f�@
' BUILDING PERMIT PERM'-�� °°NTRDL#
DATE VALUATION �,�z,i3Q LOT TRACT 8 4 8 6
ViV
JOB SITE 78,742 .111GiAVAY I AI APN li4.1-0310-024
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
pt)rlA'i°.,o,(ti
�; a.l<.CIL� Lta..l,•dl .ta[S.4 .01rAli— 'Aa"t\IAr1A rf-urr
L
A%,4'At,
v7w 8 ,ttEwpOii BLVD-m-t13o hiC:iN` nLF.Y m E, not.
CC)51.1'1. MESA CA 926`71' RANCHO .tLf ~A.ttAGE CA 92270
(760)'776-4:330 CnLY U. 9
USE OF PERMIT
4
5-%U- S.F. SBEU.,100MMER .IA.13-tau (3, npl: V-11 i
NOV 0 6 1998
,}/ h
YQt.1.ir{6�.�,ACJA� �'Y 1�II,«a7.l�,t,J J TY0FL° 4 Qp jI 'q
i
St Ci3nT(;33"A.[,CONS'.l'fiUCTIOTeT AND PLAN CRFC K
LESS P1:E•TMD FEES
T'OTAL PURAUT FEE -04 Ob El NOW
RECEIPT I DATE I By I DATE FINALED .
S-3,422.45
.$c7S0.�t1
$2.672AS
n.
t8TIAINfIRD COST 0V CONN'TIZUCT10111\1
PEMMIT FRESr1. INIMARV"
;~ RV, OEPOS.I:a'
47!0,00
101_000-49.N^000
11951,00
#.i�.lsi:IF�It:`:Ai:I'I:°'is
I+�:i-�3t1t�•�12U-(iC10
�i3S.tti!
pf iI-wlow. Turf.,
I n i-Ot2C,►-4I9- -H)
$14401
A" T iN iafi.1""tl.i., C; A i:.f•1'+; 13S - CO.f % 701-000.255-000
St Ci3nT(;33"A.[,CONS'.l'fiUCTIOTeT AND PLAN CRFC K
LESS P1:E•TMD FEES
T'OTAL PURAUT FEE -04 Ob El NOW
RECEIPT I DATE I By I DATE FINALED .
S-3,422.45
.$c7S0.�t1
$2.672AS
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
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:
Building ? Q _ % � Z
Address` U I
T4tyl 4 4 Q%At
P.O. BOX 1504
78-495 CALLE TAMPICO
LA OUINTA, CALIFORNIA 92253
owner. A► i S •IS I
Mailing I O
Address' !� 3 �� IPy I 910A••-
City Zip Tel.
fo°S1d gZG.2 y 7i L.�6 9drov'
Contractor
o Ll 1
LICENSED CONTRACTOR'S DECLARATION
I hereby. affirm that^I"am licensed under provisions of Chapter 9 (commencing with Section
x,7,000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.'
'SIGNATURE , r _ y DATE
" OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to *Its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9,(commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for thealleged exemption. Any violation. of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
(-! 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself qr,through his own employees,
Provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. -'7044, Business and Professions Code: The Contractor's License Law
does not apply -to an owner of property who builds or improves thereon,` and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
I7 i am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor,Code.)
Policy No. Company
F] Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY 1
I hereby affirm that there is a construction lending agency for the performance of the !
work for which this permit is issued. (Sec. 3097, Civil Code.) ,
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject'to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of aOplicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE/'CONST. OCC. GRP.
A.P. Number
Legal Description
�� Y•f�1 rJ/ ^'
Project Descriptiono
Aid- L. • / bs vt fi &UewAfil
Sq. Ft. 5c00 No. ' No. Dw:
Size J / Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
_Su��.. ca,►tr►.
City
Zip
Tel.
State Lic.
City
& Classif. • 76 2(048
#
Arch., Engr.,
Designer
Address
Tel.
City
Zip
State
Estimated Valuationo
(v /
Lica #
LICENSED CONTRACTOR'S DECLARATION
I hereby. affirm that^I"am licensed under provisions of Chapter 9 (commencing with Section
x,7,000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.'
'SIGNATURE , r _ y DATE
" OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to *Its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9,(commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for thealleged exemption. Any violation. of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
(-! 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself qr,through his own employees,
Provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. -'7044, Business and Professions Code: The Contractor's License Law
does not apply -to an owner of property who builds or improves thereon,` and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
I7 i am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor,Code.)
Policy No. Company
F] Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg work. for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY 1
I hereby affirm that there is a construction lending agency for the performance of the !
work for which this permit is issued. (Sec. 3097, Civil Code.) ,
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject'to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of aOplicant Date
Mailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE/'CONST. OCC. GRP.
A.P. Number
Legal Description
�� Y•f�1 rJ/ ^'
Project Descriptiono
Aid- L. • / bs vt fi &UewAfil
Sq. Ft. 5c00 No. ' No. Dw:
Size J / Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
_Su��.. ca,►tr►.
s��cf 1YPaytJ
Estimated Valuationo
(v /
PERMIT
AMOUNT
Plan Chk. Dep.
"]050
Plan Chk. Bal.
e
, p p
Const.
B
7 r
Mech.
Lj , D
Electrical
, p
Plumbing
4•• 00
S.M.I.
p .;
Grading
1
Driveway Enc.
T
Infrastructure
AE6 by
4C
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setbacktfrom Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINrL OA INSPECTOR
ss�jed•b Date Permit
AUu du w litY q$
Validation:
v
WHITE = FINANCE YELLOW.= APPLICANT PINK = BUILDING DIVISION
k
Notice:
Document Cannot Be Duplicated
Date 10/22/98
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
APN # 643-080-024
No. 17911 Jurisdiction La Quinta
Owner NameReal Property Associates
No. 78-742 Street Highway 111
City La Quinta Zip 92253 Study Area
Permit #
Log #
Tract # Lot #
Type of Development Commercial
Comments
Shell commercial building, Type V -N
Square Footage 5,500
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered
patios/walkways, residential additions under 500' square feet, detached accessory structures or replacement mobilehomes.
It has been determined the above-named owner is exempt from paying school fees at this time due to the following
reason:
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
.31 X 5,500 or $ 1,705.00 the property listed above and that -build
i ing
permits and/or Certificates of Occupancy for this square footage in this proposed project may -'now be:; ssued g
Fees Paid By CC/Pacific National Bank/RHI da Nevada RHITele"'oh. ne 77,643,30
j
p
Name on the check V
^
By Dr. Doris Wilson��
Superintendent
Fee collected /exempted by Juanita Green Payment Received $1,705.00
Check No. 71898
l
Signature
NOTICE: Pursuant of As " mbly Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run fr m the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Dislrict('s)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
MAR -11-99 THU 10:53 AM RIV, CO. FIRE P&E INDIO
James M. Wright
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Clues of: `
Banning
0
Beaumont `
8
Calimesa
O
Canyon Lake
O
Coachella
O
Desert Not Springs
4
Indian Welts
O
Indio
a
Lake Elsinore
La Quinta
0
Moreno Valley
d
Palm Desert
O
Perris
O
Rancho Mirage
0
San Jacinto
Temecula
Board of supervisors
Bob Buster,
District 1
John isvaglione,
District 2
Jim VerwW,
District 3
Roy %Mlacn,
District 4
Tom Mullen.
District 6
FAX N0, 1 760 863 7072 P. 2
RIVERSIDE COUNTY FIRE DEPARTMENT
hr cooperation with the
California Department of Forestry m7d Fire Protection
210 West San Jacinto Avenuo • Perris, California 82570 • (809) 840-6WD & FAX (909) 9 6810
3�� 1
March 10, 1999
City of La Quinta
Building Department
Re: Fire and Life Safety Clearance
I� �. -7- ..
49 -
County Fire Department is.granting a fire and life safety clearance for a shell
Id at 78-742 Highway 111.
Respectfully,
FRANK KAWASAKI
Chief Fire Department Planner
By "t
Walter Brandes
Fire Safety Specialist
FiAE?<WPDATA%AOUINTA%STARBUCK%SHL RLSEWPD
EMERGENCY SERVICES DIVISION 4 PLANNING SECTION 4 INDIO OFFICE
82.675 Highway III, 2nd FI., In4o, CA 92201 6 (760) 663-6686 4, Fax (760) 663.7072
. CBS ,� 1 A �'ta ItA.i f
��. 0�� . �"� JON TANDY
N
�. 3 0 RfCo 37630 Medlool Ave.
BUB�UB�Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED fir.
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑., REINFORCED, MASONRY ❑ FIRE PROOFING
JOB LOCATION n s p j / Q `��
REPORT SEQUENCE N0.
TVPdi.Of STRUCTURE/a_.-..---�.J�.I�A�'J
P`ERMITNIO`'.-'['CJ• .�.1
DATE/
DAV OF WEEK
MATERIAL DESCRIPTION p _ ��
'T
ARCHITECT
INSP CTOR
. CHARGED
ERS
(�
ENGINEER
ASSISTANTS
. CHARGED
INSPECTION GENERAL
DATE CONTRACTOR
SUB
CONTRACTOR W9 1 l�:5 S�2SL
I I P610
4✓
�Se-
CAP P14,7e5 —�-S , S k S ,,K
W �f•J �^` B F� � ��
COPY SENT TO CLIENT
TINUED ON NEXT PAGE ❑PAGE
OF'
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS, SPECIFICATIONS, AND APPLICABLE SECTIONS OF THE.
GOVERNING BUILDING LAWS.
/)� Z7�
SIGNAURE F REGISTER SPECTOR
�.3 8� 0
DATE OF REPORT REGISTER NUMBER
��; Infonvation
/r ®To Build On
Engineering.• Consulting • Testing
CLIENT le. 19
DATEq'q &'
Architect >9e—o-e k - —i Ano .
J1" %
Engineer ik/lVi<
Contractor 1�- �►
INSPECTION REPORT
Page 1 of _
PROJECT (Name)
(Address) 7-•7y ><%,�. ,.n� /�%
REPORT NO. An.Q 1 t-)
Building Permit No. 9RL)R — 11-4
Plan File No.
Govt. Contract No.
OSA-or OSHPD #-
Other
INSPECTION
MAIL SAMPLING QTY
MATERIAL DESCRIPTION
INSPECTION CHECKLIST
—OSHPD
Concrete Cylinders
_ Rinf.: Rebar
_ Plan & Specs
—OSA
_Cement
_ Rinf.: W.W.F.
_ Clearances
—Specialty
_Mortar Samples
_ Rinf.: Tendons
_ Positions
_Mechanical
_Grout Samples
Conc.: Mix #/psi .3000
_ Sizes
Electrical
—Masonry Prisms
_ Conc.: Mix #/psi
_ Laps
_ Future Continuity #/psi
Roofing
_ Masonry Block
_ Conc.: Mix #/psi
Concrete
_ Fireproofing
_ Grout: Mix #/psi
_ Consolidation
Masonry
_ Units (block or brick)
_ Mortar: Type/psi
_ Mortar Batching
—Struct Steel
_Asphalt Concrete
_ Units: Block
_ Electrode Storage
Prestress Conc
_ Roofing
_ Units: Brick
_ Torque Applied
—Pile Driving
_ Reinf. Steel
Steel
_
_ H.S. Bolts
_Fireproofing
_Steel
—Waterproofing
H.S. Bolts
_ Metal Decking
—Non -Destructive
_Tendon (PT Strands)
_ Electrodes
—Soils Technician
_ Other
_ Fireproofing
_Batch Plant
_Other
Other
_ Corrective action required
_
Bolt Pull -Out
_ Other
_ Corrections completed
REMARKS
M
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, substantially complies with approved plans,
specifications and applicable sections of the building codes. This report covers the locations of the work inspected only and does not constitute engineering opin-
ion or project control.
INSPECTOR NAME L / A - ,/y
(I'dn Clearly)
INSPECTOR SIGNATURE
PSI -B-900-170(2) / f
CERT. NO. 20-136 ! l x%79
DATE—///,)4
°
r