0205-246 (RC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am,licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel W Professionals Code, and my License is in.full force and effect.
License # Lic. Class Exp. Date
d LO
693077 �� 07.13112(
Z r— Date kl 1 -ot Signature of Contractor/f
JF -
m OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ � f
License Law for the following reason: o
Z_ ( ) 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
LO
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
C) Cc I hereby' affirm under penalty of perjury one of the following declarations:
Lo F2 O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( �1 have and will maintain workers' compensation insurance, as required by
U
O Q Section 3700 of the Labor Code, for the performance of the work for which this
CL:
� Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver VfATL, J.-UNLi Policy No. 1,4142864.91
ob =)
r C7
(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
rr Code, I shall forthwith complyrwith those po visions.
Date: /7-1 1-1A . Applicant_
, f
Warning: Failure to secure Workes', Compensation -Covee isulawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensration;-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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) _ •.�.' Date /-
BUILDING PERMIT PERMIT#
020S-2"
DATE VALUATION $5010AIC11 LOT 0105 TRACT
JOB SITE
ADDRESS ig,44 � t�'�a oRA . r t�I' =.),r,T ..ic
T
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
J PAUL
ORR BF ii.LD
79-440 CORP "QR.tM Crlt.�'�E'� WAY 0102
7 -570 snwa.iw, 'D I.,Am 3 -un t3. D
LA Q-1-TINTA CA 922S3
PAUMDESERT CA 9 141"? 11
( 8)360.6632 MIX 139=
USE OFFPERMIT
CJAN3yCI LVODE
U,
1
COMMSP,01AL T1- "F1' OCCUF.. ivY .1'•INANCr. OFFICE (UC,C.. 71
CONTRACTAMOUNT L.131
P01mrr FEE tiUA"I
COMSTKU s DON FEE 101 -000 -418 -ON 1414.,"
PLAN CHECK R.% 1014=43-9,318 43-'•318 066.3)
-M&CH,4NICALF.E 101-000-421.ODO 02.30
ZLZCTRJC.A L 1ZZ 101-000.420-000 $01.80
1'LUMBINO FEE 101.000-419.000 $'M,4o
STRON10 MOTION FE - COMM 100-000-241-000 lS2t;.5t3
a iCi Cit4d \.+.�'1 !.•i.Cd....+'.L'1..0,i'tT t.�Cd.l!W�.
' � Q
LEDO I P �Ct) T+ : 3
�7 Si. .S'l v�
o`fvC1, i?
tIMAL,i
JUN 0. J L?<' KWIT FEES D y NOS
CROFLAQU1NTA
FINANCEDEPT.
RECEIPT
DATE
BY..
I DA F ALE `�
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
12
- /L-
• 2- 2 v
Final
Final G
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 Paris,
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 om—
Utility
Utility Notice (Perm) f Z
COMMENTS:
-
:e�tslaarrl�
;fele DT yr RIVERSIDE COUNTY FIRE DEPARTMENT 7 01- 441 v Ca f
In cooperation with the �'�- fi l0 5
of California Department of Forestry and Fire Protection
3,�a�i
210 West San Jacinto Avenue . Perris, California 92570 . (909) 940-6900 • Fax (909) 940-6910
'fes'
June 3, 2002
4EaJIpltAfdl
Off Builders RECEIVED
Tom Tisdale
Fire Chief
77-570 Springfield Lane, Ste. D
Palm Desert, CA 92211 J U N 0 3 2002
Proudly serving the
unincorporated
Re: Non -Structural Building TA Plan Review ORFS BULDERS
areas of Riverside
02 -BLDG -129 / Balboa Thrift & Loan
County and the
Cities of:
Fire Department personnel have completed a review of the plans you submitted for the above
referenced project. Please be advised the following conditions or corrections must be completed and
Banning
approved by the Riverside County Fire Department before a building permit can be issued.
Beaumont
1) Fire sprinkler system plans for the tenant improvement area must be submitted to the Fire
Cahmesa
Department for review, along with a plan/inspection fee. The approved plans, with Fire Department
.;.
Job card must be at the job site for all inspections.
Canyon Lake
❖
2) The building sprinkler monitoring system must be extended to provide an interior notification device
Coachella
within the tenant space. Plans must be submitted to the Fire Department for review, along with a
40
plan check/inspection fee.
Desert Hot Springs
Indian Wells
3) Provide either a separate Knox Key Lock box, Model 4400, 3200 or 1300, mounted per
4.recommended
standard of the Knox Company or provide key(s) for inclusion in the general building
Indio
Knox Box. If the building/facility is protected with a fire alarm or burglar alarm system, the lock box
.;.
will require 'tamper" monitoring. Special forms are available from this office for the ordering of the
Lake Elsinore
Knox Box. This form must be authorized and signed by this office for the correctly coded system to
❖
be purchased.
La Quinta
'�•
4) Install portable fire extinguishers per NFPA, Pamphlet #10, but not less than 2A1 OBC in rating.
Moreno Valley
Contact certified extinguisher company for proper placement of equipment.
Palm Desert
5) Approved building address shall be placed in such a position as to be plainly visible and legible from
Penis
the street and rear access if applicable. Minimum of 6" lettering is required for suite identification. In
•;+
strip centers, businesses shall post the business name and suite number on back doors as well as
Rancho Mirage
the front. All addressing must be legible and of a contrasting color with the background.
San Jacinto
Please contact the Fire Department Planning & Engineering staff for final inspection prior to occupancy.
Temecula
All questions regarding the meaning of these conditions should be referred to the Fire Department
Planning & Engineering staff at (760) 863-8886:
Board of Supervisors
Sincerely,
Bob Buster,
District 1
FRANK KAWASAKI
John Tavaglione,
Chief Fire Department Planner
District 2
Jim Viable,
District 3
By
Roy Wilson,
Walter Brandes
District a
Fire Safety Specialist
Tom Mullen,
HAPEWMATALLAOUINTAMWECTSM IMPRW2-BLDG-128.doc
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District 5
EMERGENCY SERVICES DIVISION • PLANNING SECTION • INDIO OFFICE
82-675 Highway 111, 2^d FI., Indio, CA 92201 • (760) 863-8886 • Fax (760) 863-7072