0304-082, 0304-085 (CONR)LICENSED CONTRACTOR DECLARATION
LJ 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
04 W Professionals Code, and my License is in full force and effect.
n License # Lic. Class Exp. Date
I W 435ff3:f 13 C" .43 J i.0 02/2812(
� / r'
o Z r ` /'Date ` �f «; Signature of Contractor
O-�
F- O0p
W OWNER -BUILDER DECLARATION
_J L)
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
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).
Cl) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
o_ cli
U Q WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and willmaintain 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 STATE FUND Policy No. 15429$343
(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 sh II ff rthwith comply with,tf�ose'p(a4ions._�
Date: , .�'r s Applicant -%� �! J tt
Ir / �� -
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.
7 r
/Signature (Owner/Agent) - �� f ` Date"/Z.-Z. T_
BUILDING PERMIT PERMITp
CC�t�-�'�
DATE � / �,,._ VALUATION LOT TRACT
t l . &292,49403 W11) 1
(,
JOB SITE
APN
ADDRESS 46--W DUNE k)UMS ROAD
649-011:CI-01.3
OWNER
CONTRACTOR / DESIGNER / EN (NEER
L Q C"0140RF. iAr.013 C)P .iFi?t-.)JAI.3 Wrfl,f
SS s,4COYX-R. t".ON.M.R.L7C'F,tO)d'f}1f;.
V126'7140N1FnLY AVE "C',
'5'73 70 29 F'ATIJAS'HWY 0701
PALM T)FMRT C.A, `72.60
i'UCC;AVALLEY" CA 92148l
('760),36-5-8691 C.LIAg 251-413
USE OF PERMIT
FOU1r1D.i� ION
FOUNDATICYN ONLY PERTs IT. 4576 SQ..i VASSEM BLY BUILDING (LA
Q11114TA CONOI'.J':CJATION OF 19HOV.l1, O ITNUISRO)
NO WORT; AUTHORKLE-D BEYOND SLALi LEVZL.
A/C -- COMMERCIAL. 4,956,00 SI'
COTS T RAC'T AXOUlNT 21755,,34 8. 0 0 i. S
7tlA ,TIM Con, UII" C6J!1tlS"TRUC:'.Q3.'ON
2!92A94" -
P1aRAur1'W SMMVhk1 `11
(11ONSTIIEIC'M9FEE 101.00041N-000 l�6,31�+g0
PLAN c•HFCK FFNI* 101-000-439-318
FV,E DEP051P1' 1 Ct 1-Cti10 31)> 1 t) $7Sb, 0t)
FL.l". CTRICA1, WE $:0.62
!sLC3MBINO I 1 Gt1 �4'; cJ>419.001t�, $133.50
.
CIIi1%DIN0 F0nK, 101-000-4,23-000 $19.00
.
171?VELOJkFTR IMPACT FEE
.A.R 1' !N PURI IC P:IACES • COM?2.70-000-445-000 $,pi f2 o
.
%tC1'C7170N AM 1''Ll.9 CIM',L`I'';.
*12,712.64
T,E:39 M.-PADDEW
-x"750.00
'�A Se'�'�d1J.L.: L• �,Tikl 9a'��.IG ,6�+...�7�'
V�1:.F. �?'d4:
`IJJ
1TY O LA QuiNTA
FINAPtCE DEPT
RECEIPT
DATE f / : / -r
8Y
DATE FINALED
INSPECTOR
�ti
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings . O
Ducts
Slab Grade
Return Air
Steel
Combustion Alt
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Pool Cover
Sewer Connection . 0 3 $
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
LICENSED CONTRACTOR DECLARATION
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
04 LU Professionals Code, and my License is in full force and effect.
C) License # Lic. Class Exp. Date
Ts C19 C�;1o?1`*_/-
W
Z Date
Signature of Contractor
r�
_J b (D
I.- Q OWNER -BUILDER Dtl6LARATION
r1_ H.1
LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
0 -
co License Law for the following reason:
Z ( ) 1, 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).
coI am exempt under Section LO i—, B&P.C. for this reason
C14 Date Signature of Owner
0C%I
a0)
WORKER'S COMPENSATION DECLARATION
<
Z
< a: I hereby affirm under perlaity, of perjury one of the following declarations:
P 0 1 have and will maintain a certificate of consent to self -insure for workers'
< . LU LL compensation, as provided for by Section 3700 of the Labor Code, for the
_J
_J _J performance of the work for which this permit'is issued.
<
< 0 1 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
0)U')
- permit is issued. My workers' compensation insurance carrier & policy no. are:
It z Carrier'1115 FC!,I-D Policy No. i �1 U�113_03
w5
r--0
(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 11 that if I should become
subject to the workers' compensation prgv)sioinp of 5ectiqh 3700 of the Labor
0
Code, l,0&,,f#Pvyth comply with�hosrvioviE ons..
pjx
Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives / of this City to enter upon
the above-mentioned property sef�,6?pe ion,ns ct, "
.purpq s.
nature (Owner/Agent) -LI/
Ig /—, - -e " I Date
PERMIT#
BUILDING PERMIT*
DATE 40)A13, VALUATION vx) LOT.
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER EN (NEER
W, -VAT4 Wrll� MM
;�2)'PDKMi C( ' -,' C
. � -,_ �a
44
:372574), 29 PALNL.1 HWY A�,X) I
'Ch 92261"Al
Y1XC1..VA..',XZ71`.' A WZ R 4
2533
USE OF PERMIT
Ci. IJ 0I. QV,4; 5Q.1-;'. A��S"KJ,Y kiUItUTT7_, jt,$ t_,-,(.Xis 1
V -H NON 1WHAKI-ERED, VQ41ftl-
NUMMAYO
K90JANW�Mpt.g 11
"0711110341 51ir11I1CV Mi..' COMM i. 41
APR 3 0 2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB-TyYrAL 11011 AIX0 ].�LMT ic HMICK
$I qfi. 9 21
ZD, v�
r4 I)w", sq o'w
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
95
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
. /6.m
Exhaust Fans
O.K 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
751
Final
Final
POOLS - SPAS
BLOCIiWALL
APPROVALS
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
Pool Cover
Sewer Connection
.p .-sl
Encapsulation
Gas Pjptng
Gas Test
Appliances
Final
COMMENTS:
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 Z 44fl-10 5
Utility Notice (Penn) • dD 5
Certificate of Occupancy
T4&t 4 XP 494um
Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 46-300 DUNE PALMS ROAD
Use classification: ASSEMBLY BUILDING
Occupancy Group: A-3
Type of Construction: VN
Owner of Building: LA QUINTA CONE. OF JEHOVAS WITNESS
l d��
Building Official
Building Permit No.:. 0304-085
Land Use Zone: RL
Address: 44-267 MONTEREY AVE. "C"
City; ST, ZIP: PALM: DESERT. CA 92260
By: STEVE TRAXEL
Date: 07-01-2003
POST IN A CONSPICUOUS PLACE