0107-278 (TT)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
�I
iJe' F,•�
Dater ;r 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). k
O I am exempt under Section B&P.C'.-for thiVreason'"-_
Date ' I ci t Signature of Owner's
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.
(titJ; 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:
Carver
Policy No.
PUNIGNT C.SO}VIPM43 1" 6?!1sf61{3�,'9f3�°9
(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, an agree that�ikl should become
subject to the workers' compensation-provisions�of Sectio X3700 of the Labor
: Code, I shall„forthwI th comply with ikos )provisions.
-Date- w� ^ 2� , Applicants �'it °' ' tet
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`.( l
Signature (Owner/Agent) �- •- Date Z` /x
BUILDING PERMIT PERM T#
DATE r VALUATION LOT �A.� '�'p TRACT
UVWXX
JOB SITE
APN
ADDRESS ,�i +ny A �,�✓-'f�^Y HIGHWAY3.11 J
FA9-0204 7
OWNER
CONTRACTOR / DESIGNER / EN (NEER
19651 l.YE'`.�t' 4.�AR1s
1„0nQUMt"l.A CA 92253
YOUMIU, RANCH CA 82610
USE OF PERMIT
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'�,� TRAILER
71I0VJP 1` 'ilGi7'MP�.L PW�+P ION A�3e+i`06ULidt� C'ER 1AUP 1N 1) ;- 301 '
VA��fa't.TICY 1 :300.00 Li
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SUMWARY
TROMP CONSTRUCTION 'G'R AILEJ D €1.000.423mOV) 1200M
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IFLI a3 C?,• "� > ► �iC° >: FjWS A '.4 x�i C'EW
$1120 3.itt�
1
,I JUL 3
2001 .. IT, Y°'.WE NOW
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CITY MANCE
A pEP.! T �-
RECEIPT
DATE �,
0
BY
DATE FINALED
INSPECTOR
FF��
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
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
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 Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
i 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:
P.O. Box 1504
78-495 CALLE TAMPI.CO
LA QUINTA, CALIFORNIA 92253
July 26-, 2001
Mr. Bart DiSalvo
Clark Contractors
19651 Descaetes
Foothill Ranch, California 92610
f
SUBJECT: TEMPORARY USE PERMIT 2001-301
Dear Mr. Di Salvo:
(760) 777-7000
FAX (760) 777-7101
The Community Development Department has approved your request to establish a
temporary construction trailer measuring 8' by 10' -to be used during construction of
the proposed Jack in the Box restaurant located at 79-724 Highway. 1 1 1, pursuant to
Section 9.100.170 of the Municipal Code, subject to the following conditions:
1. Obtain a building permit.
2. - Dust control measures shall be employed during any on-site activities.
3. Install one 2A1OBC fire extinguisher inside the trailer by the exit door.
4. The trailer, if elevated off the ground, shall be skirted with metal or wood siding
material (to hide wheels, axles, etc.). The skirting material shall be painted to
match the exterior color of the construction trailer.
5. No . temporary signs .are permitted unless separately approved by this
Department.
6. Mounted close to the front door shall be a written notice informing emergency
personnel of your 24-hour emergency phone number that they can call in case
problems arise that need your prompt attention (i.e., minimum 1 " high letters).
7. The trailer shall be removed before .scheduling a final inspection for the
restaurant, but no later than January 25, 2002, unless an extension is granted
by the Community Development Director.
8. The City may elect to add Conditions to this application request to mitigate any
problems that arise not previously addressed herein.
TUP 301 JackBoxTrailer - 51 greg
This decision may be appealed to the Planning Commission provided the necessary
paperwork and filing fee of $175.00 are filed with this office within 15 days.
If you have any questions, please contact me at 760-777-7067.
Sincerely,
J Y HE AN
C UN T DEVELOPMENT DIRECTOR
RO SDELL
Ass o to anner
Enc.
c: Community Development Director
Building and Safety Director
Code Compliance Department
Fire Department
Betty Sawyer, Executive Secretary
TUP 301 JackBOXTrailer - 51 greg
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