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00-3072 (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 246399 B 03131/2( Date Signature of Contractor 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. ( ) 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 FIY14D Policy No. 15$5821-09 (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. ate: Applicant 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. I r 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. re (Owner/Agent) Date ' 00 BUILDING PERMIT PERMIT# 0�T03-072 DAT VALUATION LOT TRACT $0 t JOB SITE ADDRESS � APN t 1 OWNER CONTRACTOR / DESIGNER / EN (NEER WNiH"DS CfJ.W.l NM INC . ED GRIJ814 004MKL COl+I`TRACTOR P(? BOX 111 3236K. W11.11OW 91RI" a"F CIi AT WI , .�F ORO �►Y;L. ZS656 WNG BFACH C"!3 .�h;5G6 (362)426.9225 CBU6 . 06206 t ' USE OF PERMIT CoArS jrlRCLXL1 IW0I? :L iNTZRIOR RFMODVL (COF'MER.TING F?.AOd.,F,.HARDWARE TO 1.01 v.-,) CONTRACT AMOUNT 450,000,00 W RMI"'1" cosr or COXISTRUCInon 450,0W,0D FERA r FKE film . CaNSTRUCT10N FEE 101.000.416.000 $1,864,58 PLARCHEC K 7E-9 101-000-430-318 yF,665.36 FEE DEPOSIT 101=000.439-31.8 •SI,500.00 F,f.3Wt; R1Cr91 FF? 101-000-420-000 $219.10 S' RO1,10 MOTON FEE• - COMM 100.000.241.000 SQ4.50 OR,ADINO PEP, 101-000-423-000 $Z0.1b0 .ART 1N PUBUUC PLACES° - COl! I.701.000»256.00() $2250,00 ;"I •: . r „ r r.' i SI 33-•CWAL C:OME"RITC'IlOhY AND PLAN CIS 46 11.2.211 L703 PrXK-PATD T, = S 411500100 TOTAL MERM FEES DIVE NOW 94,611,126 Yll RECEIPT DATEr� DATE FINALED INSPECTOR 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 ? F/;S Address CJ Owner Mailing Address/16l%, T 0 4ht44Q" P.O. BOX 1504 J&495 CALLE TAMPICONTA, CALIFORNIA 92253 City I Zip Tel. X;4e�&A> Contractor Address State Lic.I City & Classif. Lic. # Arch., Engr.,: �/ Designer ? /7�_/43,7fewl /2�O/J. AIF Tel. , !SS 3203 Zip�� State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 700p)�t_D,t inion 3 of the Busines and Professions ode, and my license is in full force and eflect� 7 SIGNATURE �' [ DATE OWNER -BUILDER DECLARATION I fj reby 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 the alleged 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: 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, 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 or 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 1 1, 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.) 1-1 1 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 n Copy is filed with the city. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed it the permit is for one hundred dollars ($100) valuation or less.) I certify that in the performance of the workfor 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., It, alter 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 Ihereby 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 slate 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 a0plicant Date Mailing Address City, State, Zip A00-40.-;;z'D APPLICATION ONLY BUILDING: TYPE'CONST.T_OCC. GRP. 3A A.P. Number Legal Description Project Description X11 Sq. Ft. No. No. Dw. Size Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ - 2!515- 5 3 Aimated Valuation /`j �nO • ^O 410 (� PERMIT AMOUNT Plan Chk. Dep. 4t, Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL REMARKS ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Validation: WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION TANDY`S INSPECTION SERVICES, INC. PO BOX 13766 - PALM DESERT, CA 92255-3766 OFFICE / FAX— 951.769.9717 PAGER 760.776.3339 SPECIAL INSPECTION DAILY I WEEKLY REPORT TYPE OF INSPECTION PERFORMED JJ �. L Ll :V r -y PERMIT NUMBER TYPE OF STRUCTURE �_G Vil jll f . .1..i Nrz JDATE �� ' PROJECT ADDRESS (INCLUDE STREET ADDRESS AND CITY OR COUNTY) 1_ ik- i M u "_ja , ZI_a. PROJECT NAME QNCLUDE COUNTRY CLUBIBUSINESS PARKlCORPORATE CENTER ECT. NAME) ARCHITECT " �•i.�r9-.,.7 .`� ��-haat=•�� ENGINEER �Gia+t�'�Ur..� �i�l�k�1�aL_��'1f %�5`C,c.:<_rrl�,S GENERAL CONTRACTOR 3.'�' t� t'lJl.-.` �: �'�.� Ti'• still' azc^'_x-,?'� :.s•c�` , SUB CONTRACTOR DESCRIPTION OF WORK INSPECTED WELDING INFORMATION WELDERS NAME CERTIFYING AGENCY NAME AND NUMBER PROCESS AND ELECTRODE F SAMPLE INFORMATION TIME SUPPLIER TICKET NUMBER MIX NUMBER AIR TEMP SAMPLE SLUMP WATER TIME IN TEMP ADDED -MIXER LOCATION TAKEN: LOCATION TAKEN: I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE A30VE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS. SPECIFICATIONS & APPLICABLE BUILDING LAWS. J / /.rte _...._ .�Jir�- 'I.•/ INSPECTORS SIGNATURE INSPECTORS CERTIFICATION AGENCY AND NUMBER Craig E. Anthony Fire Chief Proudly serving the unincorporated areas of Riverside County and the Cities of: Banning Beaumont 4. Calimesa Canyon Lake 4. Coachella 4.1- - Desert Hot Springs Indian Wells 4. Indio Lake Elsinore La Quinta r. Moreno Valley Palm Desert Perris L Rancho Mirage San Jacinto `, Temecula Board of Supervisors Bob Buster, District 1 John Tavaglione, District 2 Jim Venable, District 3 Roy Wilson, District 4 Marion Ashley District 5 RIVERSIDE COUNTY FIRE DEPARTMENT In cooperation with the California Department of Forestry and Fire Protection 82-675 Highway 111, 2nd Fl., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072 October 27, 2004 Harold J. Havens 6700 Antioch Plaza, Ste. 300 Merriam, Kansas 66204 Re: . Non -Structural Building T/I Plan Reviewp g 6 ; N �"t / (t LAQ-04-TI-121 / Lowe's of La Quinta 0 Fire Department personnel have reviewed and approved the plans you submitted for the above referenced project. Please be advised the following conditions apply as a part of the conditions for the issuance of a building permit. 1) As may be necessary to maintain proper fire sprinkler protection due to constructions changes, fire sprinkler system plans for the tenant improvement area may be required to be submitted to the Fire Department for review, along with a planfinspection fee. The approved plans, with Fire Department Job card must be at the job site for all inspections. Please contact the Fire Department Planning & Engineering staff for final inspection prior to occupancy. Applicantlnstaller shall be responsible to contact the Fire Department to schedule inspections. Requests for inspections are to be made at least 72 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 Chief Fire Department Planner By � Wafter Brandes Fire Safety Specialist Cc: City of La Quinta - Building Dept. KVEAM Da M a CMUVRWECMTMAQU47L121.Eoc EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE 82-675 Highway 111, 2nd FI., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072 r�