0312-060 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
710391 B j en1 7131/0
Date/. /f ) 2�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).
() 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 CNA CASUALTY Or, Policy No. 1676652154
(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. l shall forthwith,comDly with those Drovisions._.Jy/ r
BUILDING PERMIT PERMIT#
DATE VALUATION LOTS” TRACT
JOB SITE APN .
ADDRESS W-295 MVY1I
!^ OWNER "
VVIVA&AXT WE BUS. IrRun
2001 10TT1 ST
Ble3.Y'IY.)%iWL1.9 A}2 72116
USE OF PERMIT
CONTRACTOR/DESIGNER/
01 M.L•i.Ji:l'IM OF DITERIOR STORE M°1'allYi;:i
VALUATION
COLOILADO STRUC3'U ES r9C (CSI)
5UPI 01OPTMTNLATESPAIRMAYE i
OKL DORAy.7tr'D.HMLS :^A.05762
(916)941-7900 (MLO 6949
A-7,,006,00 LS
ESS:x�.'XM4 D CON7 OF COMVIVUMON
)RIMINl�.t`ITR U3MMAR
PLN CHf.C;X Flat? 101.000.439-318 011.1189
C014.M'R1,JCT1CrN FEE 101-000-418-000 $Ij252.00
PEED POSIT 101.,000-439-3I$ 4880M
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, indemnity
& 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.
1 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. {
j 1A,
„ /�
Sigriature (Owner/Agent) �;`n�s %� ,1f.4'r1�+'*/*.�Dlat%
SIS -=AL. COl'3S_ IRUCTTt3X AND PUN CT EJ77 .
LENS PRE -1'1 ,�ID .`�'m
TOTAL 1?LMfff F DU.i,'' NOW
DATE / BY
F i f�/
N 12 2004
OF LA QUINTA
275100 i.€2D
$2,065m
4800100
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
BLOCKWALL APPROVA S
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
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:
��%ifti �/ //(/��u✓�i��^�
Building
Address
Owner
Mailing /� 1
Address Z 6V
City/ bu; V-1� �� C
Contractor l�1
Pr-�"DI Al - �c
Address
City lZip
4
P.O. BOX 1504
78-495 CALLE TAMPIC 0
LA QUINTA, CALIFORNIA 9
BUILDING: TYff �ONSq?EC 04 2003
OCC.
I I/) IA.P. Number I�OF
State Lic. It;I1y
& Classif. ,_ Lic. If
Agdrels �- ,'Ldi—a 51 t
1t I c7ae/ 86 16`1
CitiyState
nB Al Zi P17
/ Lic. # �S b
�i 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 he
affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8usiness 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
thealleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicenf fo a civil penalty of not more than five hundred dollars ($500).
I'. t, 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 improve for the purpose of sale.)
I i 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
doesnot 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.)
f! I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby 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
fl Copy is filed with the city. 0 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 ($100) valuation
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.
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.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
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 sof this city to enter the above-
mentioned property for inspection purposes.
_ Signature of a0plicant Date
Mailing Address
City, State, Zip
WHITE = BUILDING DEPARTMENT
Description
ONLY
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
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
YELLOW = APPLICANT PINK = FINANCE
Sq. Ft.
Size
140. No. Dw.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
021 o �S
stimated Valuation
2— 7' v
PERMIT
AMOUNT
IPQ
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
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
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
YELLOW = APPLICANT PINK = FINANCE
Letter of 'Transmittal
To: City of U Quinta .
Building and Safety.
Attn:
Tel No.:
Ed Randall / Greg Butler
We are forwarding:
No. of Copies
1
' 1
Date: 12-15-03
Project: 79-295 Hwy 111
(Walmart — fixtures)
P/C#: 0312-060 (V check)
Tract No.:
X By Messenger By Mail Your Pickup
Description:
Plans (shop drawings and store fixture layout)
Structural calculations
Comments: Structural content is approvable.
3
This Material Sent for:
Your Files X Per Your Request
Your Review Approval
Checking At the request of:
Other
By: John W. Thompson
Phone # 360-5770 ext. 102 .
77-804 Wildcat Drive, Ste. C • Palm Desert, CA 92211 • (760) 360-5770
•Bron Young •