0005-132 (CSST)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
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
mpensation, 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). '-
O I arn.expmpt ander Section B&P.C: fo} this reasol�
Date ;[7•r` A' r Signature of Owner A4_1fa C'
RlT(aI , "'O'ONlPENSATION 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.
(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 Sectiori 3700 of the Labor
Code, )iShgl) iorjhwith„epmply with those�prouisions;`/�% V
Warning: Failure to secure'Workers' Compensation cover ge 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 urider 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 -r eprese�ntativea`bf this City to enter upon
the above-mentioned property ford spectio -p rposis. � Ys 4
Signature (Owner/Agent) Date- �` . a s
BUILDING PERMIT PERMIT#
DATE VALUATION LOT tP TRACT
(/) . l %
4.4 3 8.1 .:i ..
$143A98-10 s� 1ST `a
JOB SITE f
APN
ADDRESS .�
794" ENVY I I!
649-020-051
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i
1,ts.(1���m?S.fyy,Z E s�� i�,,yy����i�& PI, WC
� ,
OWNE1, BUMMM,
d�Jdy.4�.t`
,: 0101. d'2.�.7��V��bi'h'V.f.�'i�900
.FtC:PO'tiR A M;i..IAS (,-A Y1301
USE OF PERMIT
i':'w5�iZOIR IAL v(
OAS a�'��7It7�?�,43xoti.'a�.�tllElAi t�3fi'C� l4
PER .cR:PPROVE1') PLANO ON11* ' r) i
CtrATRACT.A OUNT
i-SITAIATKD COST OF -CON MUCTIQU
a
.P0VM' Y_k1E 61VAMAIRY
CONSTRUCTION YET,, 101-000418-000 3.9p
P'LAX C1110K RAE '0 1-000-4?9— 3'18
FRE DEPOSIT -8900.00
tvi MHA NICA4f.. FEE
E1;:Ef TR1CAS.: FM 101-00-420-000 $166.76
PLIUMEY"a Y-189 101 -000.419 -WO $199.50
S t ROM MOTION FSt - COMM x 00-000.1A 1.000 SIX 18
4S1$ADINO ME 1103-i1C"23-Odd+') $20.00
T. EVE140,,fte IMPACT d R, $4,287.0;
A:RT I..4 1)U8:LIC'PLAC R'S - C"'OM1701.4)00-;2:5'9-000 $7!8!R+3
=P'-Tt: TAL t:SE 1401R'C;Mi?R1!t4D F —M C9F1ECJf
,�36r:P.9S
I� _ 3a :l'"J1f:1tG19s�Ji A3�.Tr,9>&T .b.rT�� �'O,d 7ro
t&+Ct p
�Y
ffJUL -6 2001
ECEIPT flNAPo
Pf Y
tTk J
DATE FINALED
INSPECTOR
•P
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
r<2 % (_((�
Exhaust Fans
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
DrywallInt. Lath
l-/-
Final
Final o�.Zr—p�
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
Sewer Connection
j���" v j l� "�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
_
Final
COMMENTS:
['- � GSA h �� dg2��.✓� �—/ G/ Q ( �!�_
l r G� h^7� /0 2- o f
�tiL tic 0 3--Uc all
rYl A I n.� �3 LCL
Aed
Fl /`�� �. 1 U l b/ - d
�+ /
l -'� T/ 1 �✓!i C 0 �� �+ti5 1 U `l e7 -O( ` v
Qd �je,.S,L �<.c/ -� G�U�v w�3 �C�•'a � Q
Final
Utility Notice (Gas)2-
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lc,4 Voltage Wiring
FRtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke DetectorsTy
Temp. Use of Power
Final
Utility Notice (Penn) 2202 ��-
Building
$MA'
P.O. BOX 1504 APPLICATION ONLY
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Mailing'
Address` 10 r A lug C -T , # zoo
City Zip Tel. cb
%'tr Its 1, 0bI-%—, 1 n.
- &r•r11.11a1JC. 01AC
Address
111 (0l . q_T1__ Ss'
Tel. 45
1-I(11C. 1 477 �,.1Z4x1
State Lic. City
& Classif. Lic. #
Arch., Engr.,
Designer Sw,p(�- <�Se7. L
Address Tel. &Zu
oLkD In PL -MA N -K 91 Z- ke
City ZiD State
gI-Ai Lic.#
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 703 1.5,
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
tot 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).
l: 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.)
II I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the proiect. (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. 8. & P.C. for this reason
Date 4,10 'Q1 Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Co pensl ation Insurance, or a certifiedl- copy thereof. (Sec. 3800, Labor Code.)
Policy No. Companyh�...T .►`, .
r7 Copy is filed with the city. O 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 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.
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 — T
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
ame 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. , f
Signature of applicant Date
Mailing Address
City, State, Zip
WHITE = FINANCE
BUILDING: TYP/E'CONST. OCC. GRP. Q
A.P. Number 104cl• 0,10-0 It ( 0 30 V i%Q,
Legal Description i r 1�
Project Description NDA 3 M. �+ • r'v� n t 6 .Z s. ->l ; ,
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback'fTom Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issueit)Date Permit
r �•
Validatedby:, inn
IIA 1 rVt
Validati n:
N of LA Qu1
YELLOW = APPLICANT
F
PINK = BUILDING DIVISION
Sq. Ft. No.
Size Stories
No. Dw.
Units
New Add ❑ Alter ❑
Repair ❑ Demolition ❑
Cis
I Aats ("A
Cc7'tS A G : J qvq)
6 2Z - 34 0
Estimated Valuation
PERMIT
AMOUNT
f
Plan Chk. Dep.�r�!�`i
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'fTom Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issueit)Date Permit
r �•
Validatedby:, inn
IIA 1 rVt
Validati n:
N of LA Qu1
YELLOW = APPLICANT
F
PINK = BUILDING DIVISION
Desert Sands Unified School District
47-950 Dune Palms Road
Notice: La Quinta, CA 92253
Document Cannot Be Duplicated 760-771-8515
CERTIFICATE OF COMPLIANCE
Date 7/5/01
No. 22219
owner NamePalisades Gas & Wash, Inc.
No. 79-490 Street Highway 111
city La Quinta
APN # 649-020-051
Jurisdiction La Quinta
Zip 92253
Permit #
Log #
Study Area
Tract # Lot # Squa`re Footage 3838
Type of Development Commercial No. of Units 1
Comments
ommercial bldgs. are a mini mart (2978 s.f.) & carwash (860 s.f.)
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:
Commercial Building
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of
.33 X 3,838 or $ 1,266.54 the property listed above and that building
s
permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued
Fees Paid By CC / Union Bank of California -Ron Riley Tele ho)ne.'r1818-865-9200
Name on the check �*
r
By Dr. Doris Wilson ?_ '-
Superintendent
Fee collected /exempted by Annette Barlow
Signaturen�i(M
Payment Received $1,266.54
Check No. 7484890
JOTICE: Pursuant of Assembly 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 from 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
:ollect them on the District('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
Certificate, of Occupancy
--- City of La Quinta
Building and Safety Department
This Temporary Certificate issued pursuant to the requirements of Section 109 of the Uniform Building
Code, certifying that, at the time of issuance, this structure was in compliance with the various
ordinances of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 1 79-490 HIGHWAY 1 1 1
Use Classification: GAS STATION/MINIMART%CANOPY
Occupancy Group: B/M/S3 Type of Construction:
Owner of Building: PALISADES GAS & WASH, INC
—T b'wl
Building Official
1111
Bldg. Permit No.: 0005-132
Land Use Zone: CC
Address: 30101 AGOURA CT #200
City: AGOURA HILLS CA 91301
By: KIRK KIRKLAND
Date: MARCH 22, 2002 (EXPIRES 4/22/2002)
POST IN A CONSPICUOUS PLACE
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, -then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer,and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-n7012
FAX: 9.60 ' 777-70,0 12.
'S SIGNATURE/DA
TY ADDRESS
PERMIT NUMBER(s)
UOL•C9T (o§L11+d • 99lg-C9Y (O9D • IOZU VD VMR `Id r t'II I Amm Cl9'Yi
WMAO QIaW • NOLLDH9 OPIINNV'U • X019LUCI SMIASUS A;>MW M
Aoop;o eplsano eta uo rWOo17 1VOlU lo319. pfd eq Ila4s Aoop wooA 1e*upel3 (9
'punoib4aaq
QLp 4iM Aoloo Bu!as84uoo m;o pue apOel e9 isnw OUIMApps 11V '346104 uI .SZ C4 do (s)6u!pgnq
Ao; .Z L;o wnw!u!w 8 eq 11049 sAagwnu =DIPPe Bw,pl! S 'elq"Idde m ss=s Arai pus *a4s 014
woo elgpael pum al4l A Alu!eld aq (3 se UOPOd s vans ul PeOVId aq I1e46 SMPPu BUIPI!nq PGAwddV Q
jwwdlnba;o 3uawaoeld AadoAd Ao; two* AQ4SMSU xQ PGWQ* 3o03uo'J
•BUW u! 0906VZ ue43ssaa Sou 3nq'ol*3014dwsd'VddN Aed sja4s4n6upxa ail; e1g831od 119eUl (9
p"a4wnd oq of waWs POPO*
j4peuoo a43 Ao; 9*W 9lla34q pau6!s pua pax!AoLane aq;snw uuo; SI43'4011a1S Avx 04310 SullepAo
04a ao; as!go 9143 W04 elg8l!eAe aAs stwo; IepedS-sW*puss &Azjado pue uoglsodIW*8*01
6upunow;o leAoAdds Ao; Auew4Aedea QAId 04A ol pe Nwgns oq;snw sueld •Auedwoo xou>l mg
(S
;0 ;Uepuvp pepuawwoow Aad pe3unouA'0olr L Ao 0='OOVV SIQPoW'"xoq )PoI AtQ)I xouA110PUl
•,.;umWvdad gild Alunoa apps eA4a o4>< Aq
peglAaseAd s1ueweAlnbw M 4Rm e*uspA*oas ul sl wapAs A 48M eta 40 ue" 943 Is% Nmoli
1. luopO11N40 duN*0110; " 4#m A(uadwoo Aapm 18001 alp JO/Pus AeeUl6u3 ItA* paaGIONI a Qq
peu6ts eq law SuSld 'quauwaAlnbim rAOS ala; eta Pow HELP waLs 043 puS'Ouped:s pue uo4s*ol
'sed4luwp44 e4 a4l 03 uuo;uo* 11u4s sueld 'n+►Wm Ao; 3uawlJSdsa QJW e43 03 susld wa3slls jinum
elp jo Ado* aullenlq auo us!wn;11e4s AadolaAappue*Ddd8 'VwAad 6u!pnnq 8;o oouenss! 043 03 A01Ad
(t
.wep" alp u!
WuwPN AuQ*'Ofp$ Acus woo algepem eq 11e40 mog 04 PaA!nbeA e41 *sA sm IQ"w4 Aul"tioA► PQ=dde
Buole pe nssaw se 2OUIP94 a4llo uopW Ague w04 .S9 L usl a eAow A* ,SZ USIA =01 IOU PWJMI
Qq ILM (rzllT. x rz11Z x rV x.9) 194uaip(4 wq IaiAeq 1m Aedn$ ails -;{o pue G s-uo;O uo4zulgwoa V
(£
Am qof ata uo peoeld s! 18uagew e!glpngwO3
Aug eAo;eq algallene aq Isnul aAnweAd Bugwedo lenplsea Md or 3s uop unp Ano4-Z o Ao; wdS
oos' L;o Awl 94 v 'epoo aald uuapun eIa w pa4s+,1gvpe OAnpomd eta Bulsn SMIPF9.1e0Aewwoo
uo4on43uo3 Ao ♦apoweA 044 Ao; maj; alai wnwlulw a has o4 peAlnbei el 3uew3A9daa aild 041
(Z
118;o
Csoa; uopoedsuy*AmA usld 3uauno Ao; 3uaw4ASdea ai!d 0IA 3os3uoo)
'3uQu4jedea am e4 o; 6upLugns o3,opd }ueu4j8dea 4Aleam lle;uewuaAlnu3 wa Aq pedweas
pue penoAdde aq 3snw sueld )1u%4 punoaBAapun;o sold** aai4,L '4umpedea wW A3unoo epiuDArd
(L
eta w*4 s3lu,ued iluq aCsAo3s lent punoA6Aepun buluWa Ao; algpuod9m aq 11940 3uwHdd`d
';luued Oulpllnq c 4 aouen"
eta Ao; suoglpup* 843;o lied a se Aydde suoplpuoo BUVAOIIW eta Pe'Ws Qq Meld •3aafoAd pe*uaia;aA
anoge ata Aoj pa3alwgns noAt sueld e4ajo melneA a Pa3aldwoo OA84 IQUU=Qd 4USUWedea aAld
4SOAR I SBID SOP"Ied 1940-66 dno
,aG"ki veld BUMPS ISHOOMP V :ab
ZSLL6 Va'BU004WA A
1,aaAag u4uMOd LL9L
vooz '9L A SIN
OlOB'QI6 ($OBi xe� . WM26" • W= MUM "owed • OrlueI MMUuS 3s m— _
uo�A�a.Aoa� ri,T puv �AsaAod fn Auawpoda(1 olu.rof!Jnr)
aqj y1rM u014o43(100 u1
LN3WJ',xvddJ- Q a-dI3 Aj,.K[103 3Q.ISUaAIX
ZOO'd VSO:S0 Z0/4S/S0 Gatz SZL Toe
'WPM UMd.
v �cl
'149=A ffi1
Zp.Lqmc
*0000-91 mpf
I 'PPV!Q
,-VWDF1 qua
!nS3o PAOB
a
agauyq oqx"
6
g!�d
*IeA OMMW
d
sly Wi
a
Womqu awl
Q
OT
puj
4
SRAM nvgmI
o•
sguudS IoH lacaQ
0
03PI uo,Cun�
40-'
I�►�$
d
guYuuag
- jo SaWO
MR puOAlunoa
fi! djO GBM
tm
al(I 9mn= Bp awd
19140 WIS
uoauos ,tun?
J-4, 7&fb,Jdi' at ivaftS4 OtvVIa -"91VA (I'9 -w/ —11M/'9 W 31d
aIO-L.1a� esn
U.a &Trole 801 729 2487 OS/17/01 09:09A P.003
Please contact the Fire Department Planning & E=ngineering staff for final inspection prior to occupancy.
Applicantliinstaller shall be raaponsible to contact the Fire Department to schedule inspections.
Requests for inspections are to be made at least 24 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 stat[ at (760) 863 -MM.
Sincerely,
FRANK KAWASAKI
Chief Fire Department Planner
6y
Walter Brandes
Fire Safety Specialist
M.1PE7KATA%AQUWrA%PRa,ECf$*LDq_P=UPM-NO.dw
FORM A•4-10 /69
1 87 46547
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
OFFICE OF THE DIRECTOR
NUMBER 2140
CERTIFICATE OF CONSENT TO SELF=INSURE
THIS IS TO CERTIFY, That A CMPMTICT (a California corporatian)
has complied with the requirements of the Director of Industrial Relations under the provisions of
Sections 3700 to 3705, inclusive, of the Labor Code of the State of California and is hereby granted this
Certificate of Consent to Self -Insure.
This certificate may be revoked at any time for good cause shown.*
— . EFFECTIVE:
IDEPAF31,MENT OF INDUSTRIAL RELATIONS
r OF T ATE OF CALIFORNIA
THE let DAY OF Je>izzy 19 90 • °
DIRRCTOR
R. T. RINALDI
����pp��// p MANA R
PYlrltl B. ASERAFT
° Revocation of Certificate.—"A certificate of consent to self -insure may be revoked by the Director of Industrial Relations at any time for flood cause after a
hearing. Cood cause includes, among other things, the impairment of the solvency of such employer, the inability of the employer to fulfill his obligations, or the
practice by such employer or his agent in charge of the administration of obligations under this division of any of the following': (a) Habitually and as a matter of
practice and custom inducing claimants for compensation to accept less than the compensation due or making it necessary for them to resort to proceedings
against the employer to secure the compensation due; (b) Discharging his compensation obligations in a dishonest manner: (c) Discharging his compensation
obligations in such a manner as to cause injury to the public or those dealing with him." (Section3702of Labor Code.) The Certificate may be revoked for
noncompliance with Title 8, California Administrative Code, Croup 2—Administration of Self -Insurance.
KK
FORM A•4-10 /69
1 87 46547
G�
ILS
4 f syste--
DIME, O C Q 12-APPROV
J B`
CASE Ni
( ,r Bracket=
t� t git C�
Off. m 2r Sq.
J
�Hote°�A 2-1/2' x 6' x 12' arm mourn (bolt -on bracket) is shipped
OF-,s6dard with Heritage fixtures unless otherwise specified.
HERITAGE
LUMINAIRE EPA CHART
Lft
Disatn"badon
NhOege
Ught scarce
Includes bracket.
to
Lutalcalre
FtnIsh
Option
HE .J
W
250
WHO
DA -Dropped Prismatic
480V
Single
on
0190' T90'
TN120'
090'
F DA
F DA
F DA F OA
F OA
F DA
H - 9' Bracket 2.02 4
3407603
4.1 4.8
—
- Clear Flat Tempered
TT - Td -Tap?
He ' -12' Bracket 2 2.6
3.9 4.8
4.5 52
62 7.2
62 7.3
7.8 9.3
Note:F-Rat Glass. DA- Drop Lens.
BUF-Buff
LL- Less lamp
LUMINAIRE ORDERING INFORMATION Select appropriate choice from each column to formulate order code. Refer to example below.
Lft
Disatn"badon
NhOege
Ught scarce
Lens
Voles
Lutalcalre
FtnIsh
Option
HE .J
A-Asymnadrical
250
HPS-High Pressure Sodium
DA -Dropped Prismatic
480V
Wen -Bronze
e8K-8'Bmc&
FK34TV - Single Fusing
FK347V
400
250,400 Watt'-
SMH
Acrylic
rF
IMT = MA Ta a
BLK - Black
PCR - Photoelectric Cartrol
PLS - Polycarbonate Shield
3407603
FK120V - Single Fusing
- Super Metal Halide
- Clear Flat Tempered
TT - Td -Tap?
PLD - Platinum Plus
Receptacle
BKS-80-WM= 4;LR Wall Mount Piave
123111CLR
250, 400 Watt
'- Glass
BUF-Buff
LL- Less lamp
MH -Metal Halide
250 400 Watt
WHT-White
GRH - Green
C -Coated Lamp
'. NO - No options
3 - Type Ill'
F - Clear Rat Tempered
FT- Forward
Glass
t..
Throw'
`
5 -Type V'
XL - High
400
SMH - Super Metal Halide
C73 - Diffused Flat
Performance
400 Watt
Tempered Glass
DA -Dropped Prismatic
Alk
MENEM
Note: PCR factory installed and
EXAMPLE OF A TYPICAL ORDER HE A 250 MM DA MT BRZ NO prowited for highest voltage. Alternate
voltages will require field rewiring.
1- When specifying Type III, Forward Throw, or Type V distribution, a dear flat tempered glass tens must be used.
2- For Intemational voltages, consult factory. .
3- MT- Multi Tap Is shipped standard unless otherwise specified. Multi Tap consists of 120V, 208V, 240V, and 27N. Multi Tap Is pre -wired for highest voltage.
Alternate voltages will require field re -wiring.
4- An 8' bracket an only be ordered with single and D180' configuration
5- Tri -Tap is shipped standard for C -UL applications. Trt-Tap consists of 120V, 2M, and 347V. Tri -Tap is pre -wired for highest voltage. Altemate voltages will require field rewiring.
ACCESSORY ORDERING INFORMATION
(Accessories are field installed)
Description
Omer Number
Description
Order Number
PC120V -Photocell
122514
DFK208, 240V - Double Fusing
DWM, 240V
K208V- Photocell
122515
DFK480V - Double Fusing
DFK480V
PC240V - Photocell
122516
FK34TV - Single Fusing
FK347V
PC277V- Photocell
122517
HSS - House Side Shield
122529
P0480V - Photocell
122518
PLS - Polycarbonate Shield
3407603
FK120V - Single Fusing
FK120V
RPP2 - Round Pole Plate
162914
RW7V - Single Fusing
FK277V
BKS-80-WM= 4;LR Wall Mount Piave
123111CLR
"Black only.
2/01
HERITAGE
PHOTOMETRICS
For detailed photometric data, please visit
our web site at www.Isi-industries.com
THE HERITAGE' SERIES
Combining proven performance, technology, and cost-effectiveness, the Heritage is
instantly recognizable by its distinguished square shape. The Heritage fixture is available
in a wide selection of light sources and distribution patterns, and its modular styling
achieves a harmonious continuity between energy efficiency and architectural design.
SPECIFICATIONS
HOUSING
The Heritage features a one-piece
aluminum housing. Comers are
welded and finished to produce
a clean, sharp appearance while
Increasing housing strength
and ensuring weather -tight
construction.
LENS/GASKET
Available lenses for the Heritage
include an injection -molded
dropped prismatic acrylic or
a clear flat tempered glass lens.
The dropped prismatic acrylic
allows for uniform distribution,
while the clear flat tempered
glass is used primarily with
the forward Throw or Type III
reflectors. The lens frame has
a continuous, one-piece EPDM
gasket for maximum sealing
to the housing.
DOOR/DOOR FASTENERS
The Heritage's one-piece formed
aluminum door frame features a
captive door fastener to provide
secure closure and easy access
with no loose hardware.
SOCKETS
Porcelain mogul -base sockets
feature spring -reinforced
contacts for long [He.
LIGHT SOURCES
The Heritage Is designed to operate
with any of the following lamp
types: High Pressure Sodium,
Super Metal Halide, or Metal Halide
with mogul -base sockets. Clear
lamp is supplied as standard.
REFLECTORS/DISTRIBUTION
PATTERNS
All Heritage fixtures are
available in fire reflector
systems and distribution patterns:
Asymmetrical (A), Type III (3)
medium distribution pattern for
increased pole spacing, Forward
Throw (FT) for perimeter lighting
applications to eliminate stray light
and produce a sharp backside
cutoff, Type XL for high
performance, and Type V (5)
distribution. Photometric data is
tested in accordance with IESNA
guidelines.
FINISHES
Each Heritage fixture is finished
with DuraGrip° LSI Lighting
Systems' revolutionary superior
baked -on polyester -powder
finishing process, to give the
fixture an exceptionally attractive
appearance. Standard finish
colors available for the Heritage
are bronze, black, platinum plus,
buff, white, and green. The f
Duraft polyester finish Q
withstands extreme weather
changes without cracking (, �
peeling. Finish is guaran
for five full years. Dov
BALLAST
High-power factor type ballast Is
mounted to the housing
reinforcing plate. Ballast is
designed for -20° F operation.
BRACKETS
A 2-1/2' x 6' x 12' arm mount
(bolt -on bracket) is shipped
standard with Heritage fixtures.
(An 8' bracket is also available in
single and D180" configurations.
This must be ordered from the
options column of the ordering
chart) Refer to Poles/Brackets
section of catalog for other
mounting options, which
must be ordered separately. A
Round Pole Plate (RPP) is
required for mounting to 3'-3"
round poles (see Accessory
Ordering Information chart).
C @us
LEM
listed for wet locations.
HE Type 3 - Horizontal
HE Type 5 - Horizontal
tlg6tU+g systems -
LSI Industries Inc. REV 2/01 10000 Alliance Road ♦ Cncirmti, Ohio 45242 • (513)793-3200 FAX (513)9841335 ♦ wwwii ndu stries.com
DEVELOPMENT
tuz
EGM2
EAGLE II
ORDERING INFORMATION Select appropriate choice from each column to formulate order code. Refer to example below.
Lomualre
Prafla
OlatlbWon
1amp
Wallace
Light Some
loos
line
voltages
Luwlcatre
Field
Options
EG2
W8jWi68 m
100
MPS -High Pressure Sodium
Pr'- PressedGlassLens
480V
18RZ=Bronn
LL -Lass Lamp
122550
150
100,150 watt
PVS - Polycarbonate Vandal Shield (Small only)
�Mutti T
IT
BLK _8
1 O = No 0ptons
WGS -Steel Wire Guard (Small only)
122552
•FusIrtg not available on small fudure
175
MH -Metal Halide
Tr -Tri -Tap
WKr-While
100,175 watt
EGM2
HPS- HighPressureSodium
BRZ-gronze
LL - lasslarrrp
/250]
—"
250 Watt
MH Metal H-,
250,'400 Wat
NO - No Options
EXAMPLE OF A TYPICAL ORDER EG2 WB 175 MH PG MT BRZ NO
1- NIT - Multi Tap Is stopped standard unless otherwise specified. Multi Tap consists of 120V, 208V, 240V, and 277V. Mutt Tap Is pre -wired for highest voltage.
Alternate voitMges will require told re -wiring.
2- Tri -Tap Is shipped standard for C -UL applications. Tri -Tap consists of 12OV, 2T7V, and 347V. Tri -Tap is pre -wired for highest voltage.
Aftmte voltages will require field re -wiring.
3- For Intentatonal voltages, consult factory.
ACCESSORY ORDERING INFORMATION (Accessories are field installed)
DeserlptIon
Order HumWr
Description
Order Number
PCE120V - Eternal Photoelectric Control
122547
FK120V -Single fusing'
FK120V
PCE208V - bftTgal Photoelectric Control
122548
FlC M - Sincle Fusing*
FK277V
POE240V - Edernal Photoelectric Control
122549
OM08, 240V - Double fusing •
DFK208, 240V
PCE277V - E#amal Photoelectric control
122550
DFK480V - Double Fusing*
DFK480V
PVS - Polycarbonate Vandal Shield (Small only)
122551
FK347V - Single Fusing •
R(347V
WGS -Steel Wire Guard (Small only)
122552
•FusIrtg not available on small fudure
® LSI Industries Inc. REV 2101
CIS ,
BUILD!� `-
C ^,T E
a
INSTALLATION INSTRUCTIONS:���4 ,r
EAGLE WALL FIXTURE G��
1. Loosen tw o captive lens retaining screws (Figure 1)
and remo ve lens and frame assembly from housing.
Remo ve ballast enclosure reflector.
2. Dr ill (3) 5/16° holes in bosses at back of fixture at
locations sho wn on template. CAUTION: Do not
alto w drill to contact wiring.
3. F, or Surface Mounting over Flush Junction Box, drill
1/2° dia. rear wiring access hole in fixture at
designated location. See template. CAUTION: Do
not allo w drill to contact wiring.
4. Remo ve metal chips from outside fixture.
'SURE 1 A C,0\11HINGE F OC ` V2° CIA: ON
FLUSH J 6N BOX
GASKETED SCREW, (1)
BOTH SIDES, USE FOR
�i ATTACHING WIRE GUARD
OR POLYCARBONATE
SHIELD. PLACE SCREW
GASKET SETWEEN
GUARDISHIELD AND LENS
5. Mak a suitable provisions in wall surface including LENS AND FRAME
scre w anchors If needed, etc., for attaching 1/4" REFLECTOR
scre ws (not furnished) at mounting hole locations.
6. Apply R TV silicone sealant to rear surface around all
dr filed hole locations to prevent water entry.
7.P osition fixture and use (3) 1/4° screws (not
fur nished) to secure fixture to wall.
8. F or Surface Mounting using Condult Wiring, thread
conduit to side or top of fixture (Side only if photocell
is used, Figure 3).
9. Wire according to local and national electr Ical codes.
WARNING: Risk of electrical shock. High
temperature inside fixture
10. IMPORTANT: Supply wire rating must be equal to or
g reater that temperature specified on fixture's
product label.
IOA. Tie an over -hand knot In the and of the incoming
supply leads
1 OB. Make certain that leads are reliably held away from
ballast.
11. Replace ballast enclosure/reflector .
12. Install lamp .
13. Replace lens and fr ame assembly and tighten (2)
tens retaining scre WS.
NOTE: Before energizing be sure -
1. Line v oltage corresponds to ballast primary voltage;
2 Lamp is type and w attage shown on ballast cover
label;
3. F or best lamp contact in socket, tighten lamp,
loosen, and retighten. -
FIGURE 3
RUBBER GROMMET, (1) BOTH
SIDES. REMOVE AND PLACE IN
OTHER HOLES FOR
POLYCARBONATE SHIELD
\ ATTACHMENT
BALLAST COVER
OPTIONAL PHOTOCELL
APPLY RTV SILICONE SEALANT ON
THREADS TO PREVENT WATER ENTRY.
IN PHOTOCELL WIRING DIAGRAM, USE
HID BALLAST PRIMARY VOLTAGE LEAD
FOR'LAMP LOAD.'
— sem• --«
saw ----,
5116' DIA. HOLE
VY NPT FOR WIRING -
4-M2'CONDUIT, BOTH SIDES
12' DIA REAR WIRING
f ACCESS HOLE
2.5116'
DIA HOLE
5/16• DIA HOLE
L/ W77t40 SYSTEPIS
LSI LIGHTING SYSTEMS An LSI IndusMas Company
10000 Alliance Road CWnnad, Ohio 45242
(513) 793,3200 Fax (5 13) 7903-0147
76-76163 Rev 1/99 Ts1357
FLAT LFEN1 \SCOTTS DALE
DIMENSIONS
r 7s7i6a^i � e
9
V t
End
14-11/8r
14.1t/s2-�
Bottom
C73 - Diffused Lens Shown
LUMINAIRE ORDERING INFORMATION Select appropriate choice from each column to formulate order code.
Refer to example below.
Lumtrralre
Prefix
Distribution
lamp
wettaoe
Upht bum
Lena
Un e
votspe'
luminaire
flsn
options
SCF '
S-=
175
PSMV -Pulse StartMetal
F- Clear Flat Tempered Glass
NFT - Will Tap
C73 - Diffused Glass
'NO - No Options
Door frame Gasket
0 - DlrecUonal'
250
Halide vertical 175, 250,
C73 - Diffused Glass
320
320 Watt
EXAMPLE OF A TYPICAL ORDER ' SCF — S — 32O - PSMV - F - MT - WHT - NO
1For international voltages, consult factory.
'Clear Rat Glass recommended with use of Directional Reflector, to maximize performance.
9/00 5K 1725
PARTS & ACCESSORY ORDERING INFORMATION
Desawlan
View from
--
Above Canopy
Lamp Ctumlier Assembly
132678
175 Watt Pulse -Start Metal Halide(PSMV) lamp
155507
250 Watt Pulse -Start Metal Halide(PSMV) lamp
146684
320 Wan Pulse -Start Metal Halide (PSMV) lamp
22187
Clear Rat Tempered Glass
View from
C73 - Diffused Glass
Below Canopy
Door frame Gasket
30162
Clear flat Tempered Glass
9/00 5K 1725
PARTS & ACCESSORY ORDERING INFORMATION
Desawlan
order
Number
Lamp Ctumlier Assembly
132678
175 Watt Pulse -Start Metal Halide(PSMV) lamp
155507
250 Watt Pulse -Start Metal Halide(PSMV) lamp
146684
320 Wan Pulse -Start Metal Halide (PSMV) lamp
22187
Clear Rat Tempered Glass
159543
C73 - Diffused Glass
159544
Door frame Gasket
30162
APPROVED BY LAITY DEVELOPMENT DEPART EM.
BY DATE
EXHIBIT
CASE N0.
812000 LSI Industries Inc.
THE FLAT LENS SCOTTSDALE" SERIES
U.S. Patents No. 5,662,407 and 6,059,422 ,
LSI's Flat Lens Scottsdale is designed to deliver high performance lighting with controlled light
distribution in situations where zoning restrictions demand sharp cut-off. It is available with a
symmetrical reflector for general light distribution under the canopy or a directional reflector
for lighting the vertical surfaces of your dispensers.
The Flat Lens Scottsdale also provides the many benefits of the original Scottsdale including,
pulse -start technology, vertical lamp orientation, ease of installation and ground re -tamp. The
Flat Lens Scottsdale carries a comprehensive 5 -year warranty on all parts, finish, workmanship
and electrical components (excluding lamps.)
SPECIFICATIONS
HOUSING
INSTALLATION
BALLAST
Each housing is a die- cast and
One-person installation makes it
High-power factor type CWA
spun aluminum reflector/housing
the most installer -friendly product
ballast is designed for -20 degree F
unit Two threaded conduit
available.
operation. The ballast is mounted
openings allow use of ballast box
REFLECTORS/DISTRIBUTION
in a separate enclosure above the
as junction box.
PATTERNS I
optical unit to provide the lowest
LENS/GASKET
A choice of symmetrical or
operating temperatures available.
A flat clear tempered glass lens or
directional reflectors are offered
LIGHT SOURCE
a C73 diffused flat tempered glass
which can be used to direct fight or
Utilizes 175, 250, and 320 Watt
lens. A continuous one-piece
limit the amount of light directed
pulse -start metal -halide lamps.
extruded high temperature gasket
beyond the canopy perimeter. A
FINISH
assures a maximum seal to the
housing.
vertical bum optical system
provides a more Worm .
Available with a white or bronze
LENSFRAME/DOOR
distribution of fight.
powder coat finish.
FASTENER
Features an integral hinged die-cast
aluminum lens frame. Door frame
closes and locks with stainless
C �� us
steel spring catch, to allow for easy
access for ground re-lamping.
Listed for wet locations.,
LIGHT DISTRIBUTION PATTERN
SYMMETRICAL
Canopy
Deck-.
DIRECTIONAL
Canopy
Oeck�s
GROUND RE -LAMP FLEXIBIUTY
The unit is opened and Changing the lamp is quick
closed using a ground and easy with the ground
re -tamping tool. re -tamping tool.
PHOTOM G
For detailed photom Clic cata;`L�t1
please contact LSI. l 3
FGS` COV
L/GIYT/NG SYSTEMS
10000 Alliance Road - P.O. Box 42728 - Cincinnati, Ohb 466242.0728 • (513)79332 �-FOI) AX"(513) 984-1335
DIST. it COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PLAN CORRECTION
J� /00Plan Check # � D ` b � a Date a
DBA POJ I S R ck e✓ Address
nr
Plans Submitted by 10 1 I�C,e C Phone(,? 0 216 2-2- 3 Ci2�
Owner �a � acC cs C,address �� 0 d 1 fes,* A LLt�n PhoneC P 4)P6 (S - 0)-00
The plans are now approved subject to the conditions listed below and the attached compliance sheet.
''l iomiltao Lrh,A 2� �o�o�ec.�I6Y� .4- (I, k+, n,, �oG+'��. C0V11, 11
b1--
C i'ar`�e
C eC9,(n. ' le -
h
G.0 co 06 A cr'('oP.,,, d 00 �i2 dry
a Tom✓ ibs, /6
Iec.P lT- rIr ✓13eW�exITA
CONSTRUCTION INSPECTIONS: Contact the Plan Checker for a
imately 80% complete, with plumbing, rough ventilation, and rough
made at least five (5) working days in advance.
TTY DEPT.
VED
FOR cogs RUCTION
InspectiQn_wti�`ficon dioA is approx-
)stalted. eq� uest for inspection should be
A FINAL INSPECTION MUST be made upon completion of ALL work including finished details. APPROVAL to operate shall
not be granted, or remodeled areas approved to operate, until the facility has passed the FINAL INSPECTION, and
"APPLICATION TO OPERATE" has been completed and PERMIT FEES have been paid.
Request for inspection should be ma e a ea t fie (5) working days in advance.
CLANS CHECKED BY Phone
34'J
I acknowledge the corrections noted herein and as indicated on the plans and agree to incorporate them during construction:
Signature
Company Usk 9
Date Z-013-101
DOH-SANA78 (Rev 1192) W -OFFICE — Y -APPLICANT — P -BLDG. DEPT.
-00 MON 9:08 AM INDIO AG COMM,
JAMES 0. WAUACE
A01CIAlud Comnls'10-
060cloa 0( Welghlf A Maasuel
FAX NO. 760'775 9049
OFFICE OF 111E
AGRICULTURAL COMMISSIONER
P.O. 80X 1089
ME11SIN CA 92502.1089
P110NE (9091955-3000
FAX (9091955-3017
82-675 HIGHWAY 111, RM 14
INDIO, CA 92201
(760) 863-8291
P. 2
WEIGIi1S & MEASUnES
P.O. Sox 1460
nNv nSIDF, CA 92502.1480
PHONE (909) 955.3030
FAX 19091276-020
DATE 5 /5� DOd _ CASt NO. PC.. ft pSJo-
DEVELOPER'S NAME: t(S/I �QO��^��"'''
ADDRESS; -30/0/ t&.�- x,,7,� 13*,:
TELEPHONE: ��/ %Q 57
• .. �Ges.t~e�-+ r' l�"�I�C.CO�"lJ�d "��s^'�.- d`- �Q•"^"�
79 y90,
Dear Developers �
After reviewing your landscaping plants, all plant material listed is not in
violation of quarantine laws goberning the (,oathalla Valley, If substitutions
do occur and they differ from plant materiel listed, this office roust be
notified immediately.
Thank you for protecting and preserving the Coachella Valley's pest—free
environment.
Agricultural Commissio Is Office
cc: Indio and 'Riverside
r
08/14/00 22:41 N0.e15 P02
AJG- 8-'2000 TUE 06;00 PM RIVERSIDE CO.HAZ MAT FAX NO. 909 358 5017 P-.02
/R--19-UU WLU 14: ub 1 PtU tU IV, I IGnL I N k , u, „v, -
f', Cooperative iced Imported Fire Ant Project
Notification of Intent to Move Soil Brom or within Quarantined
Areas of Orange, Riverside, apd Los Angeles Counties
RIFA Compliance Agreement # ' Permit #
Issuing City/County
Agency
Name of Company Requesting Approval: ALA WA
;~' a L,� -�--�
Contact Person: � �N: �G �--
Address: �Zt,� l n1 —_City: Zip: L2lola
Telephone: _(Jc�]L) 34Z¢ 4 Ll __ Fax: _( y 09 ' l co
Excavation Location: — Q O 4ti
Destination Location:
' I ACRES:
Estimated Quantity of Soil (e.g. # Cubic Yards):
AtUcipated Datc ofMoveznent:
Urgency Level for Immediate Inspection and Release: (Circle Oae) cute Medium �*+
n
Movement of Soil is Per,tiitted.
.. i
Hold Movement Until Site Checkcd - WE WILL CALL AS ,SOON AS POSSIBLE TO
SCHEDULE INSP*ECrION DATE AND TDYM.
Date Trapped: # of Traps: Trapped by: � Acres:,^ _
Date Picked Up: Comments: li�uAC �n►5PE•er- PIER#;
0 Soil Movement is Strictly Prohibited for the Following Reason(s):
Name of RIFA Project Regulatory Official:Date: % rl3—
Signature; I WAFonncw-1
Rer,a/1 ]rJ9
TS is Thorans Brothers page and grid designation i
i