0310-307 (SPIN)U)
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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
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
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
Date x'>>� % / 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:
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,
1,5 all 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, fo thelwor ers' compensation provisions of Section 3700 of the Labor
Code, 1 "shall fo,r�thwith comply with those provisions.
Da"te ��, 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
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Signature (Owner/Agent) ��r`'� �a Date
�1
BUILDING PERMIT PERMIT#
DATE VALUATION LOTS TRACT
JOB SITE
APN
ADDRESS 51-350 DEPSEW CLUB DRM
-
OWNER
CONTRACTOR / DESIGNER / EN &NEER
19R—T0119 =014
H/A
USE OF PERMIT
1913CM- .A1`1'. OUS
SPW.IAL INSPeCT1014 FOR CfI.ANOr: OF tJSIUCIHANOZ OF 00CU P,¢ N.CY
1_4 I
2003
Eh"I'MATM) COSH' OF CONM>3'Md. N
_ � 0.00
IS hu.Ry
SPECIAL INSPECTION 101.000.423.000 S��U.(►�
,TJ;B-TOTAL COM. TIM t:'1' ON AND PIAN CHECK
$1.00,00
LESS PRR-PAD FEW
$$0.00
MTA ,x!''&;%'16 rPREN DUN lid O'er'
$TiW_00
RECEIPT
DATE
Bye%%
DATE FI LED
INSP OR
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
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
OX 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
Utility Notice (Perm)
COMMENTS:
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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
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
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
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:
Cartier 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 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 $100,000, 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
PERMI
BUILDING PERMIT 0
DATE VALUATION LOT �lQ 307 COPY
JOB SITE
APN !�
ADDRESS .5I_3,M Vf!.k;KW
OWNER
CONTRACTOR/ DESIGNER / EN INEER
DR JOW DMON
y
NIA .
c > - CB110
USE OF PERMIT
'Ism (IM til R-011,13
St�FCFlt.i JNSPECT1014 FOR CHANCE OF USEICKhNOR OF OCCUPANCY
kL'MAWlaw COST OF CO NS'.CJl2TiMON
Z}ERblTr FFX SUMMARY
SPEMAL, INU)'WTION 301-000-423-000 FIM04
S`[, B- 'OTT AL t,OMYRIJrMON AND PLAT E'HFIC%
$100,00
.LESS PRE-PATIXF M
S0100
TU AL g'Is12M7' FEES DUE NOW
TIO N)o
RECEIPT
DATE
BY
DATE ALD
INS
E OR
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
BLOCKWALL AIPPROVAYS
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
OX 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
Utility Notice (Perm)
COMMENTS:
10/31/03
P.O. Box 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Dr. John Dixon
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
RE: Change of Use/Change of Occupancy Special Inspection, Permit 0310-307
Dear Dr. John Dixon,
A special inspection was performed at 51-350 Desert Club for an application of
`Change of Use/Change of Occupancy' for the existing residential single family dwelling
(R3) structure to a professional office (B), chiropractor doctor's office. The following
comments are based upon my observations and. requirements to approve the application
of Change of Use and Occupancy.
1. Provide written evidence of Community Development Department approval for this
application, i.e. Minor Use Permit. Contact Community Development Department
directly at (760) 777-7125.
2. Provide written evidence of Public Works Department approval for this application.
Submit a parking and site accessibility plan to Public Works for review and approval.
Contact the Public Works Department directly at (760) 777-7075.
3. Submit a Floor Plan drawn to scale with an occupant load analysis. The Floor Plan
shall identify the use of each room. Additionally, submit information on that Floor Plan
to provide readily achievable barrier removal to the disabled in public accommodation
facilities. Demonstrate in Plan an accessible path of travel from parking, pedestrian
walks, the main entrance and a restroom. Please submit the Floor Plan with an application
to the Building Department for review and approval.
Should you have any questions and/or if I may be of any further assistance, please call
meat (760) 777-7027. .
Sincerely,
aniel . Crawforr.
Building Inspector II
dpc