14261 (AC)`_'.. �_ •
TA
P.O. BOX 1504 i
Address 49--499 Eisenhower Dr. LA QUINTA, CALIFORNIA 92253
Owner Hotel .Assoc. 'of Palm Springs
J
Mailing
Address Same
city
La Quinta, CA zip 92253 Te1.564-7690
Contractor
owner/Builder
Address
ty Izip I Tel.
State Lic. I City
& Classif. Lic. #
Arch., Engr.,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars (S500).
u 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or 6nprove for the purpose of sale.)
G I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044. Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) -
I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
Policy No. Company
Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: ff, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS (StDO,D00), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above -
mentioned property for inspection purposes.
BUILDING: TYPE CONST
P. Number
CV
No. 14261
OCC. GRP. -
Legal Description
Project Description Addition of a bar in Montanas_
Restuarant.
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
i
}:
Estim6tedValuation $8 Sofl.0ii
X t
%
.�y PERMIT AMOUNT
Plan' Chk. Dep:f
Plan. Chk., Bal.�I U •
COnst.,•
Mech. ' A
Electrical x.
Plumbing +lb UU
S.M.I.
Grading p
Driveway Enc. t
Infrastructure
TOTAL ° .« 193.20
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
Issued by: Date
Validated by:
INS
Signature of applicant Date
Mailing Address
City, State, Zip
Validation:
By
CONSTRUCTION ESTIMATE
NO.
ELECTRICAL FEES
NO.
PLUMBING FEES _
1ST FL. SO. FT.
2ND FL. SO. FT. ®
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SO. FT. ®,
ESTIMATED CONSTRUCTION VALUATION
$
UNITS
YARD SPKLR SYSTEM
,
MOBILEHOME SVC.
BAR SINK
I
POWER OUTLET
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASH ER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 V. c
SEWAGE DISPOSAL
SO.FT.GAR ®:v c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE JPL.CK.FEE
CONST. FEE
ELECT. FEE
SMI FEE
PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
}
COUNT Y,OF.WVERSIDE HEALTH SERVICES AGENCY ,
DEPARTMENT OF ENVIRONMENTAL HEALTH
APPLICATION FOR REVIEW OF FOOD ESTABLISHMENT CONSTRUCTIONIREMODEL PLANS
NOTE: PLANS WILL NOT BE ACCEPTED UNLESS THIS APPLICATION
IS COMPLETE, AND THE PLAN CHECK FEE IS PAID.
ESTABLISHMENT NAME: f \ ` f� �� C� . C �.: r ., bts
JOB SITE ADDRESS: `(G f J oc L,, �5
rTTv•
FOR OFfICIA4 USE
OFFICE
DATE (—
$
FEE
.. ..CONTACT PERSON:- (� �:, .(� PHONE-C '<
CONTACTS ADDRESS:
OWNER/OPERATOR NAME r PHONE:
ADDRESS CITY ZIP
CONTRACTOR/ARCHITECT .NAME PHONE:
ADDRESS CITY ZIP
A. GENERAL CONSTRUCTION:
Type of construction New Food Facility Remodel of Existing Permitted Food Establishment
-Total square footage (including all seating areas) Hours of Operation
Seating Capacity for dining ' Number of workers per shift (incl. mgmt.)
B. SERVICE (Indicate ALL methods of food service to the public):
On -site preparation (cutting, cooking, assembly, etc.) Soup or Salad Bar
'Food and beverages are individually packaged by manufacturer Customer Self -Service Dispensers
Full Service Bar_
Type of customer utensils (cups, plates, forks, etc.) Single Service (disposable) Multi -service (re -usable)
C. UTILITIES (Will Serve Letters):
NOTE: Before approved plans are released, the applicant shall provide to this department Will Serve Letters. which state the
establishment is or will be connected to the utility.
- • Water Service: ,-'Public Water System NAME OF WATER COMPANY: c tJ
Private Well (Must be potable) . '
Sewage Disposal: v'Public Sewer System NAME OF SEWER COMPANY: C. �.
Septic System (must be Environmental Health Land Use approved).
Grease Interceptor: Provide from Sewer District a Grease Interceptor size requirement letter or waiverletter.
OWNERIREPRESENTATIVE DECLARATION: I certify that I have read the entire application and state that all information is correct. I under
stand that the amount of fee paid is based on my declaration of information on this form, and that incorrect information is grounds for denial of the
submitted plans. I also -understand that plans will be discarded if not picked up within sixty (60) days of approval or denial, .and that no inspection
'of my establishment will be conducted, or approval granted to operate, until all proper information requested has been received and plans have been
approved and retur d. t
Signature Date
DEH-SnN 002 (Rev 2/94) T' Distribution: WHTTE—Office; YELLOW --Customer
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W-DOWELL DESION ASSOUi
15 MAR4E STr,'. E T
WSALITO, CA 1?4965
, (415) 332-4'k"-4
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4-11
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kicDOWEll DESIGN ASSOCIATES
LArCk0jAJT-A Wjrr-:L.,, 15 MAJ?tE STREET
SAUSALITO. CA 94965
(415) 332-4409
10