0305-257 (CSCS)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
Professidnals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
`?
10391 B07131/2(Date • vSignature 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:
Carrier CTUA CASE9AVry OF t Policy No. 3 OW65,1114$
(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.81'yr
ate: _ 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 jaws relating to the building
construction, and hereby authorize representatives,of this City to enter upon
the above-mentioned prrole ygfor inpurposes 1
Signature (Owner/Age't) � .4 hn�7�1• 'i1,{}h ).g Date I
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BUILDING PERMIT , PERMIT#
DATE VALUATION. LOT 01.06-2.57 TRACT
F
JOB SITV f
APN
ADDRESS 7 -2" �Wy ll
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OWNER
CONTRACTOR / DESIGNER / EN (NEER s
wpj..- .7' :gym qtr An niyn .
E:Qi.0RAD0 8TR C T'E)Rn IPTG (m)
702 3W OTH wr
;5060 ROBERT MMIEWS PARKWAY STE i
BINT011BwLE AR
EL DORADO RltI-311 CA 95762
(916)941-7900 CmLg 6949
USE OF PERMIT
COMAMAICNAL
`
R"ISED WAS. -AW, $'NACK BAR. TO a'i I;4CIJONALDS TLKHAN'T YMP1;t ?VRMZ1QT.
SUPPLEMENT TO PERMIT,#, 0392-08:3,
C014T RACT AMOUNT 4%000.00 L9
U' 104ATM) COST UP CONM. UCMOlq
PLAN C-HECKF*,E 101.000-439-318 $260.98
CuO, NSTAUCTI014 FEB '101-000-41t9-000 a94l; SU
D
NOV 05 200.3
C�l > JIW96N 11TIMO �6'AIMPCIE C.
$662.49
FINANCE DEPT. imus PRE-PA,K) M-5
$G7,€ o
I)OTA,T PET-IffiT TS DUEE NOW
$662>48
RECEIPT
DATE )� j`�
If !f
BY /�
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DAT F1 A D
(i/1
INSPECTO
INSPECTION RECORD
J_
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 / O
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 / Q
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:
C/.i0 T (it//Cali/:18'. /10i`��P �d �W
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jam- �/��y�/�„piT io.�
/0604/1
Certificate of Occupancy
Tait 4 4aahrw
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: 79-295 Highway 111
Use classification: Commercial "McDonalds" TI
Building Permit No.: 0305-257
Occupancy Group: A-3 Type of Construction: VN Sprinkled
Owner of Building: WalMart Real State Trust Address: 702 SW 8th St
Building Official
[IM -1i«
Land Use Zone: CR
City, ST, ZIP: Bentonville, AR
By: Daniel P. Crawford Jr.
Date: 3/1/04