9910-048 (PC)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
76113.E I3 0,V.3! 120t
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:
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, amexclusively contracting with licensed
contractors to construct the project (Seca 7044, Business A Professionals
Code).
O 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:
Carver Policy No.
Mirvr& INS, F: MID
(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.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage,is unlawful'and
shall subject an employer to criminal penalties and civil fines up to $100,600, 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
fora 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/Agent) Date
PERMIT #.
BUILDING PERMIT:
DATE 1010711"VALUATION } ?RI R . LOT TRACT
JOB SITE
ADDRESS 777 1 915 0 11'EGO AY 111
APN _
OWNER
/6DESIGNER ENGINEER
R �+ yp INCCONTRACTOR
5 AL`�'i.AJ S71'C �.Fa1S 7,aV
i..idrl�`,K, i�1t .as�.i\aiiJ�urP�4.4/1`��2�IG.le A..i, Li.i tai
.20 .01 SE I T f,•1
H C 6880X 365
S1~iv"mON'1+r1 IRF AR. ?2712.
RUPT 011
'
y'�74755
/ lei%3%111'
(W)876 -321-e
-
f
USE OF PERMIT
Ftp. �30
t fri�13C 3Li4'4 C'k ,t�3 f'.Lkt. ti, 1. 3�3.0 F (� IWA1.••MAR i' {
• 3tUI;4ti',�o-1°TiG;i 3,w7G.�
1.}"L� f.01-000-439-319 -�rfiOiD,+)0
MAY rt,�Rl e01-000-,19-318 $2,0.483
ME 10-11-000-418,00M,
STRONOMOTIONRLIF- 0UN441 7100-W-741-000 S9.15
i
SAT-IMA!,iw''0Nat:Kf•KTT1tDNANDPT_raN(;PECK,
$653 (1)
1
RECEIPT
DATE
BY
Dyt JNEj
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
o
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:
City o La uinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: Walmart Stores (plans in Bldg. Dept.)
78-950 Highway 111
Applicant Contact: Christie/Joyce (501) 273 7780
Applicatio /,Circulation Dat .
Community Development Department
Christine Di Iorio, Planning Manager
Public Works Department
Steve Speer, Senior Engineer
Building and Safety Department
Mark Harold, Building and Safety Department Manager
Health Department
Fire Department
Schools Fees Paid
r-
Date
Date
Date
01%CR JIY
D to
? 7
Date
Date
Date
James M. Wright
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
cities of:
Banning
e
Beaumont
0
Calimesa
e
Canyon Lake
0
Coachella
e
Desert Hot Springs
0
Indian Wells
0
Indio
O
Lake Elsinore
La Quinta
e
Moreno Valley
0
Palm Desert
e
Perris
O
Rancho Mirage
e ,
San Jacinto
O
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 • Perris, California 92570 *(909)94D4%= • FAX (909) 940-6910
September 8, 1999
To: Harrison French Architecture
502 SW A Street
Bentonville, AR 72712
Re. 'Garden Center - ---.
LWaI-Mart. Store#1805. (NWY 111
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.
All questions regarding the meaning of these conditions should be referred to the Fire Department
Planning &aEngineering staff at (760) 863-8886.
Sincerely,
FRANK KAWASAKI
Chief Fire Department Planner
By
Walter Brandes
Fire Safety Specialist
EMERGENCY SERVICES DIVISION ♦ PLANNING SECTION ♦ INDIO OFFICE
82-675 Highway 111, 2nd FI., Indio, CA 92201 0, (760) 863-8886 0 Fax (760) 863-7072
Information
ow ®To Build On
Engineerm. Consulting • Testing INSPECTION REPORT
CLIENT l� 1 Aon.
DATE I0 Ll 9
Architect
Engineer_
Contractor_
Z
Page 1 of_4.0
PROJECT(Name) VAma,- AIZT
(Address) 0 LA Q TA
REPORT NO. IM
Building Permit No.
Plan File No.
Govt. Contract No.
OSA or OSHPD #-
Other
INSPECTION
_OSHPD
_OSA
MAT'L SAMPLING QTY
_Concrete Cylinders
_Cement
MATERIAL DESCRIPTION
_ Rinf.: Rebar
_ Rinf.: W.W.F.
INSPECTION CHECKLIST
_ Plan & Specs
_ Clearances
_Specialty
_Mechanical
_Electrical
—Roofing
_Concrete
X Masonry
_Struct Steel
Prestress Conc
_Mortar Samples
Grout Samples_
_Masonry Prisms
—Masonry Block
_Fireproofing
_ Units (block or brick)
_Asphalt Concrete
—Roofing
_ Rinf.: Tendons
_ Conc.: Mix #/psi
_ Conc.: Mix #/psi
_ Conc.: Mix #/psi
Grout: Mix #/psi
_ Mortar: Type/psi
_ Units: Block
_ Units: Brick
_ Positions
_ Sizes
_ Laps
_ Future Continuity #/psi
_ Consolidation
_ Mortar Batching
_ Electrode Storage
_ Torque Applied
_Pile Driving
_Fireproofing
_Reinf. Steel_j,Steel
_Steel
Bolts
H.S: _
_Waterproofing
—H.S. Bolts
- Metal Decking
_Non -Destructive
_Tendon (PT Strands)
_ Elec!rodes
_Soils Technician
_Batch Plant
_Bolt Pull -Out
_Other
_Other
_Other
_ Fireproofing
Other
_ Corrective action required
_ Corrections completed
_
_
REMARKS
H
1 S v O S C O E T-1 A F- S L.i` M 8 —
_ G> hj�._ .--� L��-DSI Co t_WA I.1S - -
CERTIFICA711ON OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted, substantially complies with approved plans,
specifications lid applicable sections of the building codes. This report covers the locations of the work inspected only and does not constitute engineering opin
ion ct conNol.
INSPECTOR.NA E . , r � I � ��� CERT. NO.
089 5T4 -�3�--
7 (Print
INSPECTOR SIGNATURE J � DATE -&
REPORT OF GROUT COMPRESSION TEST
TESTED FOR: Glen Wisenhunt Construction PROJECT: Wal Mart
.PO Box 16432 La Quinta, California
County Line Road 511
Dexter, MO 63825
DATE: October 21, 1999 OUR REPORT NO.: 073-90257-03
FIELD DATA:
LOCATION OF PLACEMENT Garden area, new columns, first 6'8" lift.
DATE PLACED October 21, 1999 SUPPLIER Superior
TIME 4:35 p.m. DELIVERY TICKET NO. 71993
FLOW, SEC. CEMENT
MIX WATER TEMP. OF WATER
AIR TEMPERATURE, OF 90° FINE AGGREGATE
GROUT TEMPERATURE, OF 820 ADMIXTURE
DATE RECEIVED IN LAB October 25, 1999
FIELD DATA SUBMITTED BY David Kretz
MIX DATA SUBMITTED BY
COMPRESSION TEST RESULTS
ASTM C109-93
LABORATORY
NUMBER
SPECIMEN
ID OR SET
NO.
TEST
AGE
DAYS
DATE OF
TEST
TOTAL
LOAD
LBS
CUBE SIZE
INCHES
CUBE AREA
SQ. IN.
COMPRESSIVE
STRENGTH
PSI
TYPE OF
BREAK
545 A
7
10-28-99
15,800
3"x3"x6"
9.0
1760
545 B
28
11-18-99
3"x3"x6"
9.0
545 C
28
111-18-99
, 3"x3"x6"
9.0
Hold
SPECIFICATIONS
2000
REMARKS: Test results comply with applicable
X Cubes made by PSI representative. X Cubes picked up by PSI representative. Specifications.
Cubes made by Architect's or Test results do not comply with applicable
Contractor's representative. Cubes delivered to PSI laboratory. specifications.
Respectfully submitted,
Professional Service Industries, Inc.
Paul R. Hoersting
Branch Manager
I.
REPORT OF COMPRESSION TEST
ESTED FOR:
)ATE: 16 [ �7l4 I
:IELD DATA:
OCATION OF PLACEMENT
DATE PLACED
TIME
AIR CONTENT,
AIR TEMPERATURE, OF
MIX TEMPERATURE, 0 F
DATE RECEIVED IN LAB
FIELD DATA SUBMITTED BY
MIX DATA SUBMITTED BY
PROJE:CT: 4 -,al—%'?
OUR REPORT NO.: z)-7 -3 — ') lz� Z�'57 v
SUPPLIER G',.} "'A
DELIVERY TICKET NO.fTRUCK NO.
MIX NUMBER AND PROPORTIONS
CEMENT
WATER
FINE AGGREGATE
COARSE AGGREGATE
ADMIXTURE
COMPRESSION TEST RESULTS
ASTM E447
TOTAL
DATE OF LOAD
TEST (LBS.)
DV` -3
1/7,4
SPECIMEN ( SPECIMEN
i COMPRESSIVE
MPRE SI E I
DIMENSIONS I TYPE OF BREAK
TH
(IN.) i (SO. IN.) (PSI)
I c
I
I I i
i i 1
i I
19
I
z�L'%J
SPECIFICATIONS /
Specimens picked up by PSI
REMARKS: _ Specimens made by PSI representative. _ representative.
Specimens made by Archaecl's of
Contractors representative. _ Specimens delivered to PSI laboratory.
Test results comply with applicable
specifications.
Test results do not comply with
applicable specifications.
Respectfully submitted,
Professional Service Industries, Inc.
THESE TEST RESULTS APPLY ONLY TO THE SPECIFIC SAMPLES TESTED AND MAY NOT BE INDICATIVE OF THE ENTIRE MATERIAL PLACEMENT.
'4EPORTS MAY NOT BE REPRODUCED. EXCEPT IN FULL. WITHOUT WRITTEN PERMISSION BY PROFESSIONAL SERVICE INDUSTRIES. INC.
P• / ,
PSI A-200-29 F '
O
SPECIMEN I TEST
LA
ID AGE
N 1
NUOMBERRY I
OR SET NO. (GAYS)
I
'
PROJE:CT: 4 -,al—%'?
OUR REPORT NO.: z)-7 -3 — ') lz� Z�'57 v
SUPPLIER G',.} "'A
DELIVERY TICKET NO.fTRUCK NO.
MIX NUMBER AND PROPORTIONS
CEMENT
WATER
FINE AGGREGATE
COARSE AGGREGATE
ADMIXTURE
COMPRESSION TEST RESULTS
ASTM E447
TOTAL
DATE OF LOAD
TEST (LBS.)
DV` -3
1/7,4
SPECIMEN ( SPECIMEN
i COMPRESSIVE
MPRE SI E I
DIMENSIONS I TYPE OF BREAK
TH
(IN.) i (SO. IN.) (PSI)
I c
I
I I i
i i 1
i I
19
I
z�L'%J
SPECIFICATIONS /
Specimens picked up by PSI
REMARKS: _ Specimens made by PSI representative. _ representative.
Specimens made by Archaecl's of
Contractors representative. _ Specimens delivered to PSI laboratory.
Test results comply with applicable
specifications.
Test results do not comply with
applicable specifications.
Respectfully submitted,
Professional Service Industries, Inc.
THESE TEST RESULTS APPLY ONLY TO THE SPECIFIC SAMPLES TESTED AND MAY NOT BE INDICATIVE OF THE ENTIRE MATERIAL PLACEMENT.
'4EPORTS MAY NOT BE REPRODUCED. EXCEPT IN FULL. WITHOUT WRITTEN PERMISSION BY PROFESSIONAL SERVICE INDUSTRIES. INC.
P• / ,
PSI A-200-29 F '
O