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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 Busine;s and
Professionals Code, and my License is in full force and effect.
License # Lic. Class, Exp. Date
,date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affi.rm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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, 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 t he
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. MyLworkers' compensation insurance carrier &,policy'po—are:
Carrier rTA- Policy No.
(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.,16 the
workers' compensation laws of California, and agree tha f I sho'uld become
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subi,ect' to the workers' compensation provLons of SeJion 3700 of the Labor
Code, I shall forthwith comply with those provisions.
/6ate: VIN/f '2- 7 1/07
Applicant—/
Warning! Fa/ilure to secure Workers' Compensatiog 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. e,
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is perfor ' med 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 employ
2. Any permit issued as a result of this application becomes null and voi
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for.180 days will subject permit to cancellati
I certify that I have read this application and state that the above information
correct. I agree to 'comply with all City, and State laws relating to the buildi g
construction, and hereby authoridrepresentatives of this City to enter up
the above-mentioned property for �ri�pec7� �6 purppses.
Signature (Owner/Agent.) .c::�'_Date
B UILDING . PERMIT PERMIT#
DATE VALUATION LOT TRACT
$3000V.00 Na -4- PM3
m
JOB SITE APN
ADDRESS $43-02"3 1'
OWNER
CONTRACTOR DESIGNER EN&INEER
WASHINarORUL LT13
C. F_ FRY CUNSTRUC7,109 CO MfC
74-7-70 HWY I 11, SUM 202
Po-r>ox 1769
DMIAW AMELLS -CA
"UPL': 91785
1(9-09) 501-5 a lmr)
USE OF PERMIT
M&AERCIALM&ODEL
11,4�3 SQ.I?T. TENANT 1r0PRDVEMZNT FOR RANX BUILMM'WOCC.
.T.Ypz vii cmirRucnow. viunylm. -.2aat comw
COI
HTRACT AM'01JNT 30%000.00 LS
0
ES . 77MAT1W CO&7 OF C0.N8'r1W=0X_
PURMINFERE STIAMARY
COWSTRUCTION FEE 101 -00,9 .419-000
JMAN C-8 ECK, FEE I'
MECHANICAL F119 01 -000,
H '060
ZLECTRICAL ITZ, 10i4C6-42.0
PLUMMO 'FEE '10-000-419-000 $9,2.00
SUB -TOTAL CIONSTRUCMON AND PT -M CITMK
$3,307.10
LESS PREI-PMD IMS
. $0.00
-KE -S
TOTAL PFRNUT k DIM ;KQW
$3,307,10
9 2003
oCT 0 9 2003
—_�A 99IN A
CITy OFF: ILA QUI T
-REeEfp,r*-- DATE BY DAT 171 L 1: Ul
. /0._:r I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts oe
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing 4
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 Tj
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 I I
Gas Piping
PLUMBING AP OVALS
Gas Test
Electric Final
Waste Lines LCILHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral 3
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit Q
Rough Wiring A"'I
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
COMMENTS:
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City of La Qu nta _]
Building S Safety Division
P.O. Box 1504, 78-495 cane Tampico
° La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
t
-Permit #
D 304P5 "33f
Project Address:
Owner's Name: ON L r r
A. P. Number./� c 3
Leval Description: PD oY- y e� Jac 5i -S
Address:
Cin. ST. Zip: J N /4 75
FTelephone: Id -220 -�-:,�'�•'��.f'r..
Project Description:
Contra cior—.)
Address:
.City, ST. Zip: ,%
r
,Telephone:-
- -
_
'Stit Lic.,# -
Ci L c., :
Arch., Engr., Designer:
Address:
City. ST. Zip:
Telephone:
.: ;_ . _.; :: -
Construction Type: -- 't/ Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.: S 3 D
# Stories:
# Units:
Telephone # of Contact Person: _ !
stimated Value of Project: 60 oo
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
Truss C21cs.
Called Contact Person
p2
0 Z7
Plan Check Balance
Energy Cales.
2
Plans picked up
Construction
Flood plain plan
Plans resubmitted/1S
Mechanical
Grading plan
2" Review, ready for correctio issue
/0/3p/0
Electrical
Subcontactor List
Called Contact PersonPM(II S.
p
Plumbing 1
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resu d
Grading
IN HOUSE:-
_ iew, ready for correctionsrissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.1.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees�0
f
g41
Total Permit Fees
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Of MEMORANDUM
To: Greg Butler, Building & Safety Manager
From: Planning
..... ..w-;••sem r+^�•.m
v
To CDD: 9-15--03
Building Permit Release
(this is an approval to issue a Building Permit)
The Community Development Department has reviewed the following project:
Description: —rI ( 6
Address or general location: 78 "bas , y6/
APN and/or legal description:
The Community Development Department finds that:
D- ... issuance of this Building Permit does not require Community
Development Department approval.
... issuance of this Building Permit is approved by the Community
Development Departme t.
Planning
Date
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RIVERSIDE COUNTY. FIRE DEPARTMENT
IN COOPERATION WITH
CALIFORNIA DEPARTMENT OF FORESTRY
AND FIRE PROTECTION
`"" '•` 4080 LEMON STREET, 2ND FLOOR
P.O. BOX 1549
�-i'- C UNTPr
RIVERSIDE, CA 92502-1549 .
RIVERSIDE .:+....,'
(909) 955-4777 FAX (909) 955-4886
r
JOB CARD
THIS INSPECTION RECORD MUST BE AT JOB SITE
WITH THE APPROVED SET OF PLANS
Owner I__ f . _1 _ �,i., ., Date
Location I. SoS lI La n•�„�a -
Case No. IM 03 tT oki
Sprinkler Company
Underground Visual
(Joints and Thrust Blocks Must Be
Underground Static
(200 PSI For 2 Hrs. Prior to Inspection
. Underground Flush
Overhead Static Date
(200 PSI For 2 Hrs. Prior to Inspe ion Time)
Fire Main Installer
Underground
(Joints and Thrust
Inspector
Inspector
Inspector
Inspector
Inspector
Date Inspector
Must Be Exposed)
Extinguishing System I taller
Final Date Inspector .
Fire Alarm Installer $wcpv4 h Co•+Ira
Final Date Inspector
Tank Installer
Final
FUEL MODIFICATION
Final
Date Inspector.
Date
Inspector -
DO NOT OCCUPY THIS STRUCTURE UNTIL
AFTER FINAL INSPECTION BY
BUILDING AND SAFETY
284-159 (Rev 8/02)
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ales
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��tY . a6�niiTs�� � �ilfi•� i�i���l
,� Certificate of Occupancy0 o
G OF'TBuildin & Safet Department
9► Y p
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating -building
construction and/or use.
BUILDING ADDRESS: 78-805 Highway 111
Use classification: Commercial (Washington Mutual Bank) TI Building Permit No.: 0308-331
Occupancy Group: B Type of Construction: VN Sprinkled Land Use Zone: CR
Owner of Building: Washington 1111, LTD Address: 74-770 Highway 111
City, ST, ZIP: La Quinta, CA 92253
By: Daniel P. Crawford Jr.
—�
Date: 12/30/04
Building Official
POST IN A CONSPICUOUS PLACE