0108-217 (BLCK)LICENSED CONTRACTOR DECLARATION
I herky.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
17094 3I)V O/V
Date ' k s' — Signature of Contractor -6' GG a �i �I % 0''
UW I
L/ 11641— Vi
ILDER 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.
(,,h'>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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
f:IiSMa?W €:°OMPENS,
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performahce 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:tApplicant'
,•�Failr to -se
cure -Work s' Com ens on.covr e- rage eis 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 hjs
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 propgrty for inspection purposes.
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Signature (Owner/Agent), l'l 164 020 Date+
BUILDING PERMIT PERMIT#
DATE / VALUATION LOT 01013-211 TRACT
JOB SITE ` ""
APN
ADDRESS
79-72.4 119GHWAY I I1
017
649-020-017
OWNER
CONTRACTOR / DESIGNER / ENGINEER
WADIP, G0 i1ANG (JACK. INI THE BOX)•a'
LARK C;O.k��,RAK "isd�R TKC°.
1.965i DBIJICAKYRIS
SAXD;iRt:'o !'"A (11,dl23
110UDEULL.Rt X'1111 Cha 82MO
,945))581-6577 tCET."Y 31,1.5
USE OF PERMIT
.:v+.,y%f'.yt�y..r�;�iy�{�...�5 y�'iet,'�q g qy pq q�gy a� p /� EN
5iqq�i�yiy��.�4,C.[.Y7.'-I l(°�)I�fi+`jk l.r}�'�4 PER 2-1f.eg.'TN,
(,�3`�I•yA•.�TY�it)H Buil CII, - .34
t�1:w@yiiI.apre.32
WAi.L,; SOUTH TH PR4". P - 129 I.F. COMBO WAU, PER PLAkl
6 FT. WALL 370.00 LP
ENTn"ITM COST OF WINIMMUCIMM
%M.00
FSUMMAIN
COi' PSTRUCTION F4Z 1011-000-418_000 $117.64
311y�q am, ayr Ag p{,.•yy«y(p,,�:�;yy7�,y�p /.,,7 y y ��p ¢�y�++/�,�•
`T'C„�"?°�°a b•VAiC11544!.r11V.iP C46tl. CEJ Ki/9 WTtd:h .AE
(�a j S
A�`t.).�f.�l
O e LENS k'1�.`���)('AIDYM
$0.00
AUG 2 2 2001
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATEBY
DATE NA jjD��_
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 —
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
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
/��/ v
Main Drain
Bond Beam_
T
9 6 _
Approval to Cover
Equipment Location
Underground Electric
Final/�%L
Underground Plbg. Test
Gas Piping
PLUMBING APPROVAyS
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:
�� i?r��i L��C���S(/i26r �D�✓�/�
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Bi" # ' ?'A City of La Quinta
Building 81' Safety Division
Permit # `' P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sh �°`
Project Address: Z 1 Owner's Nam • I n
i
A. P. Number: - V Z D Address: q �O
Legal Description: City, ST, Zip:
Contractor: Telephone:
Address: 'n Project Description:ell
City, ST, Zip: CA lVreh 6 l
Telephone:
hone:LIq9
I
State Lic. # :17 Z Ciry Lic. #: - 11 t ( - L
Arch.. Engr.. Designer: r d"
Address:
City. ST, Zip:
Tele h
on .
Con tru
P
Cos ctio
n Type: OccuP
ancy:
State Lit. ProJect
bP
e (circle one). New
Ad '
n Alter
Repair Demo
q.
Nam tact Pero l� S Ft.: #Stories: # Units:
Telephone of .Cl5niact Pe'rson:jfoo D Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
f$ Submittal Req'd Recd TRACKING PERMIT FEES
Ian Sets Plan Check submitted Item Amount
,Structural Calcs. Reviewed, ready for corrections Plan Check Deposit
Truss Calcs. Called Contact Person Plan Check Balance
Title 24 Calcs. Plans picked up Construction
Flood plain plan Plans resubmitted Mechanical
Grading plan 2°" Review, readv for corrections/issue Electrical
Subcontactor List Called Contact Person Plumbing
Grant Deed Plans picked up SAM.
H.O.A. Approval Plans resubmitted Grading
IN HOUSE:- '^' Review, ready for corrections/issue Developer Impact Fee
Planning Approval Called Contact Person A,1•P.P•
Pub. Wks. Appr Date of permit issue
School Fees
Total Permit Fees
Pim
C ity,of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: 128 if freestanding (screen) wall -Trash Enclosure.
208 if retaining &.freestanding wall--- All 6'
Jack in the Box
79-724 Highway 111
Applicant Contact: Nancy Patterson (858) 350-6251
Application /Circulation Date:
ECOVE e_g-di
Community Development Department
AUG 0 92001 ite
CITY OF LAOUINTA
PLANNING DEPARTMENT
Christine di Iorio, Planning Manager R E C:IMDa e
Public Works Department
Speer, Aenior 5ngineer
Building and Safety Department
Greg Butler, Building & Safety Manager
AUG 0 q 2001
PUBLIC WORKS
22
Da
PLANS ARE IN THE BUILDING DEPT.
Date
�e
City of La Quinta
Developers Project Approval -Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or dela
ytng approval.
Project: 128 if freestanding (screen) wall -Trash Enclosure.
208 if retaining & freestanding wall--- All 6' 7
Jack in the Box
79-724 Highway 111 v�
Applicant Contact: Nancy Patterson (858) 350-6251
Application / Circulation Date:
3 Date
Community Development Department
4E� A1eA'C>t z
I�
Christine di Iorio, Planning Man a er Date
Public Works Department
\
ve Spee Se or Eng' eer Date
Building and Safety Department
Greg Butler, Building & Safety Manager
PLANS ARE IN THE BUILDING .DEPT.
Date
LOCA
ENVIR
A i'iESGJ UTION OF THE PLANNING COMMISSION OF Tlft.
CITY OF LA QUINTA, CALIFORNIA, All-Ji-3ROVING THE
DEVELOPMENT 01-' A 2,869 St7.UARE FOOT -FAST FOOD
RESTAURANT WITH DRIVE-THROUGH LANE LOCATED AT
THE NORTHWEST CORNER OF HIGHWAY 111 AND
DEPOT WAY ON APPROXIMATELY 0.9 ACRES
CASE NO.: SITE DEVELOPMENT PERMIT 2000-687
APPLICANT: LYONS, WARREN & ASSOC., INC. FOR JACK IN THE BOX
j _-
WHEREAS, the Planning Commission of the City of La Quinta, California,
did on the 9t" day of January, 2001, hold duly noticed Public Hearing to consider the
request of Lyon, Warren and Associates to develop a 2,869 square foot Jack in the
Box restaurant with drive-through lane in the Regional Commercial iCR) Zone on
approximately 0.9 acres at the northwest corner of Highway 111 and Depot Way
within the Jefferson Plaza Shopping Center (Specific Plan 96-027), more particularly
described as:
Being Lot 1 of Parcel Map No. 28573 within a portion of Section. 29, T5S, R5E,
San Bernardino Meridian (Assessor's Parcel No.: 649-020-037); Pad #1 of
Phase 2 of SP 96-027
WHEREAS, the Architectural and Landscape Review Committee of the
City of La Quinta, California, did on the 3'd day of January, 2001, recommend approval
to the Planning Commission of Site Development Permit 2000-687 by adoption of
( rENI` Minute Motion 2001-01, subject to conditions. -
DESK WHEREAS, said Site Development Permit request complies with. the
requirements of "The Rules to Implement the California Environmental Quality Act of
1970" as amended by Resolution 83-68, in that a Negative Declaration of
ZONII Environmental Impact (EA 96-325) was certified by the City Council under Resolution
96-71 for the Jefferson Plaza Shopping Center on September 17, 1996 (i.e., Specific
Plan 96-027 and Conditional Use Permit 96-028). No further environmental review
is necessary. No changed circumstances or conditions are proposed that would trigger
the preparation of a subsequent environmental review per Public Resources Code
ST" Section 21166; and
r-
78-495 Calle Tampico, La Quinta, CA 92253
(760) 777-7015 voice; (760) 777-7011 fax City of
Quinta
Building Depadment
.Fax 0
=,:3o D
To: Tracy N. Lindquist, LWA Inc. From: Greg Butler, Building & Safety Manager
Fax: (858) 695-8964 Pages: One
Phone: (858) 578-8380 ti Date: 01/17/01
Re: J160017 Address Request CC: Greg Trousdell
u wrgenz u rvr review u rlease a.vmmenz u rlease Reply u rlease necycle
Per your request, the assigned address for Jack in the Box (Parcel 1, Parcel Map 28573,
APN 649-020-037) is 79-724 Highway 111, La Quinta, CA 92253. If you have any questions
regarding this matter, please call.
l