9610-072 (MISC)LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
I— -C=hapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
p =) M License #. Lic. Class Exp. Date
r LU �• ���+t AR , i2r.a1/ t1
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ZO � /Date ? !: -a7f • G{. Signature of Contractor r` q !
U 0)OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ D_ License Law for the following reason:
U
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
N Date Signature of Owner
ON
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d Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO - Cc 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 U r() I have and will maintain workers' compensation insurance, as required by
O U Q Seaton 3700 of the Labor Code, for the performance of the work for which this
Z permit is�skyq ,:�My,�workers�tcompensation insurance carrierz,&Ypoligy no. are:
Carrier Policy No.
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: If) : t . t3 f 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
t*, construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
�lgnature (uwner/Agent) y K = /� �+ a a" r y Uate ►1 z - l - ti� �`
PERMIT # CONTROL #
BUILDING PERMIT
4254
DATE 1QJ23/96 VALUATION SZ�y� �• � LOT TRACT
_
,,yyam••� q 1 4 �
ADDRESSOB SITE , -� 411 t +C'e"[� Ila V
APN !6941���-042
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA�t�or�r+�, �,_ !:?aC���,T., c�. �r.t�� PLAZA
pr, r,C t 1'Or:1�7s C011U,
7914) CALLE "1't NIVIL{7
10906 WiLS.i•I ltr'.:dLVD., 7llt VLOOK
L11 til. N ('A CA 42253
LOS ANGFsIX-S CA 9IN124
O10►5M-7037 C*RL0 3I 0.7
USE OF PERMIT
ROOF 1\40M 10 ANTENNA AND COhl'WNICKFION EQtJIPNIINC JM8TAfa,1VrI N
VAt.OKifOK 25.000,10 LS
i'V,AAtIT i* E, N, St.l110MAitV
Ff1 f>i+'f, ef'i'-52Sifdt4
FLAN +:'IfFM Vfif's 10.80
s`O 'i'Ctc-iCylION V.iih T1ii-4UIt tkFi-ODU 1251-40
�:.f.6.s'r: "f'i3 f�;At. I� f�;Fi 1 i.t i-tllNi-Q',?U•l1Uli x:+3.(}tt
s;'['Hof<ft;+ NtCYr10N tTf? - C'6jMNI 100-000-2441.0 0 $335
SUR -'t`OTA!,t''O S'T'RIUk;'110NANDPLAN CUECK
S454.05
Q C. NS PRE -PAID FEES
G ^ ` �.
D R:''t1t,: .ttMUF kERS ORK,, NOW
OCT 31 1996
-$250.60
By
RECEIPT
DATE
BY
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
OX 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
POOLS - SPAS
BLOCKWALL APPROVA S
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
..
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City of} La Quinta
��Building.& Safety Division
P.0' Box 1504
78-495 Calle Tampico
La Quinta,.CA 92253 .
Building Permit Application and Tracking Sheet
Project Address: 7� 140 CQ"` QyVI 1 irL' O�vher's'Name: ar, 1 o F, Mo 1lz se,vv!(,P�r
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A. P. Number: I ly17, " bib " O, � L Address: 2l9s �!r I l \1J�i SL�1 C `
Legal Description: AYGZ
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Contractor:
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Address: Project Description: MOiaA C4 • "
Cin•.ST, Zip:
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State
GState Lic. # : City Lic. #: jUIl 0q� j �o Q %'nA5 li�Al, .esu'
Arcli. Engr.. Designer: \jPiG } C�YI"�� W ?h,L "W 1VA pS5 1°AU�/lV�ytl/ ✓ f c: l i
Address: 5a S•. �YIIPt
City. STS Zip: 1{46 2✓1 UQ. 9 L D
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Mff 9- S am X ` . ,004 24
Certificate of Occupancy
City of La Quinta
Building and Safety Department
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 compliance with the various ordinances
of the City regulating building construction or use.. For the following:
BUILDING ADDRESS: 78-140 CALLE TAMPICO
Use Classification: . ROOF ANTENNA & EQUIPMENT
Occupancy Group: B Type of Construction: VN
Owner of Building: LA QUINTA MEDICAL COM'L
PLAZA
Building Officia
Bldg. Permit No.: 9610-072
Land Use Zone: COM
Address: ' 78-140 CALLE TAMPICO
City: LA QUINTA, CA., 92253
By: DANIEL P. CRAWFORD JR.
Date: 8/5/97