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0401-022 (RC)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of i Chapter 6 (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 771,00 AB ! 1D'40JV Date 4�4/)-!l't/ Signature of Contractor—,/r/ OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: v ` "` `� r• — •( ) 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 Sections B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION u. 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 STATE 17U11D . Policy No. 0469633M (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:,, r' Date: �7� :. nt Applicant IIA/ V1i Warning: Failure to secure Workers' Compensation coverage is, nlawful 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 emploring 2. Any permit issued as a result of this application becomes null and v work is not commenced within 180 days from date of issuance of permit, or cessation of work for 180 days will subject permit to cancell I certify that I have read this application and state that the above informati correct. I agree to comply with all City, and State laws relating to the buiconstruction, and'hereby authorize representatives of this City to enter the above -mentioned property foorrriinspection purposes./ Signature (Owner/Agent) r�-'`���%�te BUILDING PERMIT-,--", PERMITS DATE + VALUATION LOT ' ~TRACT } - JOB SITEt ADDRESS 7i 9-20. 5 .-�,�ii 1.i11 iSOVY1 V ��lt•,1'F; WO APN _ OWNER •" CONTRACTOR / DESIGNER / ENGINEER WAI.SdLMU' REAL ='ATT'MTJTA FACE►' Irf DT_7V.M©PW2 U-r r CORPORATION, 30 PaA'013,!3w*TO 0115 39217SCONE 3T;PE T. ' CA 92618 SA'tn"7:AR OSA CIA 954-01 (701)523-1 22 CBMI. USE OF PERMIT CONDOWMAL REM M L"C'iRitMEMCi:A , REMOrM. (QUA.KEP, C-ITY BANK TI) 636 SQFT, 08" OCCUPANCY, i YUNN SPRINKLERED, OCCUPANT LOAD 1, 2601 CDC VALUATION 34000.DD La PTUTMW FEE SUMMARY NIF. VPO3!T 101=0t00-43S-31S 4350,00 PLAN CI3WK FEE 101--000-439-319 $206.03 CONSIRUC1;1013 MEN 101.000-418.000 93i100 #REC�14AIdCAt.fP9+�i? - 101�l3tl0�tl.w3=0fJ4 �t9.5t9 , ELECTRICAL IEEE 101-000-420.000 M.60 TFROY+iO h110TION IFFS - CC MNI i 0©-000-24.1-000 Si3B- OTAL CCSNX71=OPd AND PT-M CUM. 0589.50 - LYISS PR&PPM PFES 43511/00 jiow JAN 2 0 2004 ' ITY OF i ;�_ DATE . BY♦/ DA FINALED INSPECTO v �� 01 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 FireDlace P.L. Grills Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath / POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover " Equipment Location Underground Electric Underground Plbg. Test , Final I 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 Final COMMENTS: T t�� -Final t Utility Notice (Gas) Jr-v.�AL S• ELECTRICAL APPROVALS Temp. Power Pole - Underground Conduit Rough Wiring r Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final " - Utility Notice (Perm) If I ;,ogoi- ozZ } Gu BOX 1504 APPLICATION ONLY Building 78-495 CALLE TAMPICO Address LA QUINTA, CALIFORNIA 92253 Owner Mailin BUILDING: TYPE CONSTg OCC. GRP.C� Address �OZ . A.P. Number Pity Zi Tel. WOrpm, Legal Description Contractor Project Description�Zl/ Address City Zip Tel. State Lic. City & Classif. Lic. N Sq. Ft. /_Q / No. No. Dw. Arch., Engr., Size Stories Units Designer) A,t,, New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. o �a o e 00 City lZip State W J Lic. q LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm at Im alicensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3thof the Business and Professions Code, and my license is In full force and effect. SIGNATURE DATE �� 0 OWNER -BUILDER DECLARATION Estimated Valuatio 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, after, 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 PERMIT AMOUNT the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) o! Division 3 of the Business and Professions Code, or tnat. he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit • Plan Chk. Dep. W 3_5-0 subjects the applicant to a civil penalty of not more than five hundred dollars ($500). r 1: I, as owner of the property, or my employees with wages as their sole compensation, will v Plan Chk. Bal. do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and COr1St. 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 O Mech. .: �LI� S'Q or improvement is sold within one year of completion, the owner -builder will have the burden . Electrical of proving that he did not build or improve for the purpose of sale.) &0 II 1, as owner of the property, am exclusively contracting with licensed contractors to con- Plumbing strucI 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 S.M.I, such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) u Grading I'. I am exempt under Sec. B. & P.C. for this reason Driveway Enc. Date Owner Infrastructure G WORKERS' COMPENSATION DECLARATION dk I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Ci Pow Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Policy No. Company 1`7 Copy is filed with the city. ❑ Certified copy is hereby furnished. TOTAL CERTIFICATE OF EXEMPTION FROM REMARKS WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (E100) 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: If, after making this Certificate of Exemption you should become ZONE: BY: subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code.) Side Setback from Property Line Lender's Name Lender's Address FINAL DATE INSPECTOR This is a building permit when properly tilled 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. Issued by: Date Permit 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. Validated by: Signature of applicant —Date— Mailing Address Validation: City, State, Zip WHITE = BUILDING DEPARTMENT YELLOW = APPLICANT PINK = FINANCE Certificate of Occ.upancy ' Incmwanim�� G OF 9� = 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 SUITE 800 Use classification: COMM Building Permit No.: 0401-022 Occupancy Group: B Type of Construction: VN SPRINKLED Land Use Zone: CR Owner of Building: WALMART REAL ESTATE TRUST Address: 30 FAIRBANKS #115' City, ST, ZIP: IRVINE CA 92618 By: STEVE TRAXEL �a Date:-2-27-2004 Building Official POST IN A CONSPICUOUS PLACE