0302-190 (BLDG) + CFOU)
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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 Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
43:7323 .131 3 1 fiJ�
•Date � h? � 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).
( ) 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 the
performance of the work for which this permit is issued.
V,4) I have and will tmaintain 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 91T4,TE I+UML) Policy No. 22 - CIO 0N141
(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 pro i ions of Section 3700 of the Labor
Code, I shall forthwith comply with those" p�rov sgs.
,,,Date: 2 //1 1 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.
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 authoriz� representatives of this City to enter upon
the above-mentioned property4for inspe tion purposes.
Signature (Owner/Agent)4 Date—'?/-
- BUILDING PERMIT PERMIT#
DATE VALUATION W1500.) LOT TRACT
JOB SITE / I
ADDRESS 79-440 40 CO 'PORA E ClUaRR DR. 01
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
J. FAM
M9IJ.A CvL,' C;CCi.9b?r.R,U 11003
79-440 CGRA—` RAM CILITYL C JURUM
50 827 29 M.1 S FITCAWAY
LA taZ1'NTA CA 9 2215 3
MC11tOW00 V.ALLEW (...A 0-2256
X760)363.19911 C%V1 6574
USE OF PERMIT
GINERa1311 �T)�3
1400 S.I. ` FNAWT I9liP1'eOVEt ENT; PER APPROVED PLA143 (DR-
DRANDERSON).
ANDERSON).NVIRSTYGATIO3 FEE I? P031-YrD FOR. WCAK HIk3c3 Dow-,
WITHOUT PEPVUT.
VALUAT10W 4A300.00 0 t
iidfr 0.Ts' C4)f }'G.i: XYJ_ .Y'iJG'6
ysYi!'E/'.'8lbd
t��+��,yy]]pp/��y}+�-gg ==•• ,�{' y�(� ��������yyqq.;weYA•.6LbIIkSJiED
d” X:e,B�:.11e•4AJ1.� �i FT Y9UIYCYdC.1.4 RM M1
PLAN CHECK FZ•Ii 520120
CONSTRUCTION FFE 101-000-•4.1 S S90&. A
'MR-CHANICA1,M 1tile0t3W� 1,&1-0t1t? T S01100
FL,EC RICAL F29 1011-000-42€1-000: $110.0
ftutlu.rwa FPI? 101-000.42 9-000 U9•00
$483.00
INVI MAT1OAt FFLI 101 -OW -423-0M$482.00
r '
f
y
SIS WIMTAL C 10MMUMION ANIa PLA?l• C1M+: K
$1, X29.20
Iho I"'R -2'AM FE-EA3
$0.00
Now
&1,22: .�O
FES 2 5 2003 ; k.
CITY OF LA 0 INTA �
RECEI !6;DA
EU PT, _ BY
.. t
DATE "ALE,
INSP R T
..! ,. ,; i.
• • I
{ 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 I
Exhaust Fans
O.K. to Wrap I
F.A.U.
Framing
sj D3 A
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall 1
_
Exterior Lath 1
Drywall - Int. Lath t
,
i
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs 1
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
I
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Ficial
Plumbing Top Out }
Equipment Enclosure
Shower Pans
_Jim
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
AE�—
I
Final1,f
Utility Notice (Gas) li
ELECTRICAL APPROVALS
-�iY�� ell
F�� p� �I&AzqL. 6K
Temp. Power Pole i '
Undefground Conduit r
Rough Wiring —_
Low Voltage Wiring 1
Fixtures
Main Service
Sub Panels I '
Exterior Receptacles
G.F.I.
Smoke Detectors 17
Temp. Use of Power
t
Final
Utility Notice (Perm) I
J
.. �Certificatof.a e Oc"c'qpanc.y
0
C4Y.of La.,Q Uinta.
-Budding .and .Safe(y-,,V art, OF
'.This 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 with the various ordinances
of the City regulating building construction or use. Fo"r the follMowing:
BUILDING ADDRESS: Y 79-440 CORPORATE CENTER' DR. rySUITE 111
Use Classification: COMMERCIAL TI.."DR. ANDERSON"� Bldg. Permit No.: 0302-190
Occupancy Group B ; Type of Construction: VN Spklr Land Use Zone: CR :. s
Owner of Building: JrPAUL _ r Address: 79-440 CORPORATE CENTER DRIVE
3 City LA QUINTA, CA 92253.E
By: DANIEL P. CRAWFORD JR.
Date: 4/22/03 • r.
Building.Official, - ,
POST IN A.CONSPI000US PLACE
..-