0304-032 (CSCS)_N LV
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LICENSED CONTRACTOR DECLARATION
..,1-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
31.1103' tS ,, ,,,...•;---- oe''/P: l PAC'
Date ` r Signature of Contractor
OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ � License Law for the following reason:
Z_ ( ) 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
W� 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).
<°) O I am exempt under -Section B&P.C. for this reason
LO
N . Date Signature of Owner
O'kC\l
Q WORKER'S COMPENSATION DECLARATION
" p cc I hereby affirm under penalty,of perjury one of the following declarations:
p O 1 have and will maintain a certificate of consent to self -insure for workers'
k X W compensation, as provided foF by Section 3700 of - the Labor'Code, for the
'i O J Q performance of the work for which this permit is issued.
} m Q (� ( ) 1,,have and will maintain workers' compensation insurance, as required by
{ O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn Z permit„is issued. My workers' compensation insurance carrier &policy no. are:
c ? Came'r LIP�ERTY MUTUAL Policy No. WA263D'[10 0901t13
` Cy j
Q (This section need not be completed if the permit valuation is for $100.00 or less).
O 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.v compensation laws of California, and agree that if I should become
3 �^ subjeZTO the workers'. compensation provisions of Section 37,00 of he Labor
Code, I shall forthwith comply with those-p ovisions�„
Date:;�,_�� Applicant•��-�' i
Warning: Failure to secure Workers' Compensation c 4c 'v age 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
I whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of.thls applicaton agrees to, & shall, indemn4fy_-
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& hold harmless the City of La Quinta, its officers, agents and employees.
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�+ • 2. Any permit issued as a result of this application becomes null and void if
fv- work is not commenced within 180 days from date of issuance Of SUCH f
i permit, or cessation of work for,180 days will subject permit to cancellation I
•. I certify that I have read this application and state that the above _information i
f • correct. I agree to,comply with all City, and State laws relating to the bulldin ,
construction, and ?hereby authorize representatives of this City to enter upo,
the above -mentioned property for ins:ection ur•oses.
Signature (Owner/Agent) �' �-•%! -® Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
.. -pt4 30903
"r $55 ,�,M1, 60 PAR. 5
_.
f •• .'� c� ?
dOB SITE ' -
ADDRESS 7h1-'9.1t1'dA� SAY
APN
dt�k.9-4�t0-d318
OWNER.
CONTRACTOR /DESIGNER / EN INEER
'Z ARG-1gr CORP
WE 114II' VG! T UPSM CONnAt: TiN0 C ,,
1000 knCC)T'::,u':I'!t'.i u,
CC 'PRA T. P #�100
MWEAVOUS MO 35403
,IRV-M:I�' CA 92606
(9o)663.080.0 c.,Z ul ITn
USE OF PERMIT
r`C7�wG1Ai:.
124,313 SQ.FT. TWA14 fi0,573 SQ:FT. CA1ZDEN CTI'Z "V1q'02:",;.,'
r'lo PEW SPRIN'KL R. INCLUD%,,I-01"J-BUIUX EA3,91ARIT
ACREE•i EAST D C or {i u 1L �ncir- t AND IaD i Jl4V peGt2r t IAr C? V
PORCH/PATIO 3F
SP.ILINKLAE?E ?i4; 8Sl:tyl ,1°
AIC -- COMMERCIAL, 124,313.00 3F
LVONTRACT ,P MOUNT 4, �`X�,619.id1 i.�
'31AXrED COST OF C10149rRtICMON
5,579MI.80
2k'Ea" = V= SUMMARY
CONSTRUCTION FEE 10,1-000-418.000 $14697.50
'
PLAN CHECK FRE4�i9-{3{1Ckd3�-31$ $li3,Qi14.83
FE& DEPQ31T 101.0►30�43g-318 .,Si2040.00
, s
102CHANICAL FIB 101-000-421-000 $613,00
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RLEC1 RIC," FED:' 101-0004M,0010 $Z982.72
PId1031'114113 FEE 1 R1-000-4't 9-000 U40.15
STRONG MOTION FRE - CO M 1_00-000441.000 $1,%71.g1
,
GRAOING FEE 301-000-423-000
DEVE16OPER IMPACT FEE
ART ;N 1 UDL1C PLACES - 60MI 270-000.445-0€'10. i $27,89121
'
-MM-'1 WAL C+a3 1t C92I tIa P i CH WX
$308,687.88
1M3 1IZZE,-?AI)1"W0
412,000,00
• � 'O3[A1G 1'" t1 17." Ey' 5 DVE NOW
tMIM7M
JUL 30 2003
5 Cyr• LA A .
DEPJ.
FI9!lP.t3CE tTE3'T:
RECEIPT
DATE C
BY <_ -- -�..
D IN EO
INSPECT
.r✓l' � ` 1 :fir. .
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ng
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
f
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
y
Drvwall - Int. Lath
//
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings
Main Dram
Bond Beam
Y'
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
t
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
-
COMMENTS:
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Final . _.. .
Utility Notice {Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit =
Rough Wiring
Low Voltage Wiring
Win Service
Sub Parcels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
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Final
Utility -Notice (Perm)
t1 J t �•' ,-�tarw`y.ne.�r��. SAY^f+K'T'b'�jF•�i"*J7!!A'{''�i'�'4Ji'ml'�"."TPi►R:A��Y"' ��"�rr, '�ir'�.q''T`<; h'i�'`r''a`bt ,N ^,:r�7Mrrirs��yav,.t ...r ta.�-a,,h •M_r -••
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COUNTY OF RIVERSIDE COMMUNITY HEALTH"AGENCY _[ ASSESSOR'S PARCEL NUMBER
DEPARTMENT OF ENVIRONMENTAL HEALTH — —
APPLICATION -FOR WASTE WATER DISPOSAL APPROVAL
APPLICANT'Submit this -form with four copies of a SCALED plot plan (1"=20' to 1"=40' SCALE) drawn to County specifications as indicated on the attached
check list. Anon -refundable filing fee is required„when the application is submitted: Check must be made payable to the County of Riverside. Approval of this
application shall remain vatid•for a period not,to�exceed one year from date of payment.
LMS #
Agent Contractor, Contact Person
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Address City State Zip
b� uie ti Sv;fr *MVIC lea s AI a
Telephone
7M-X4%•2Z3A
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Address City " State Zip
Owne.� f T
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Telephone
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AQ @/ .ST%�S 7��'S�' it I LA &aZt,
OJob
Prope . Address-- City
La 0.xr
Zip
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Lot Size 1
Water Agency/well
Use of Permit, P/P, SUP,, PUP, etc.
Legal Description
DBA -T, p l nq
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Dwelling! MH Site Prep., etc.
Signaiur of Applica t
Date
FOR OFFICE
USE ONLY
CHECK'BOX IF REQUIRED
i
If any boi is checked, this application shall be considered rejected until the
❑ Detailed, Contour Plot Plans Required (1 to 5 foot interval)
information is provided and the fee paid. Resubmittals later than 90 days
.after date noted Below may require repayment of fees. ;;•,
❑• Other
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❑ Holding Tank Agreements Completed ,,
❑ Staff Specialist Lot Inspection Required
❑ Certification of Existing S.D. System Required
Thomas Bros. Page Grid'' ,
W❑
WQCB Clearance Required ,•. /
(Attach for, DOH-SAN-007, Santa Ana Region Only)
❑ Date Lot Inspection Completed: Initials
U)
.7
CI Spoils Percolati W Report Required.. _1�1:
-
Remarks:
Maintenance Booklet
❑ Special,Feasibility Boring Report Required
❑ Provided
• "''',
❑ . Rereview Required'--:' Initials Date
r
❑ Final Inspection by,Department of Environmental Health is required.
Please call 24 hours PRIOR to inspection:
C/42 / Soils Percolation'Boring Report By 's" tr ,-. Llc/P o ect #, Date
Soils Map Page Soil Type } Approved By Date
No. :of Systems
Type of System(s) , .
No. Dwelling Units M"77
(1)'Septic Tank
Soil Rate
Grease/Sand 7-1-CY
'
❑Holding Tank ` O Replacement
❑ New ❑ Addition5►.es►1w
Bedrooms, Fixture Units`
Grea e',IInrtccp/� -rra� -
0_Existing ❑ Connect to Sewer
Gal.
/, p61ei Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft.
Bottom Area
Ft
ft. rock/ sq. ft. running ft.
Install tLine(s) ft. long ft. wide
of Bottom Area
Inlet Tested Depth ❑ N/A
with min.* inches rock below drainlines
V
Proposed Bottom Tested Depth
or
Z
Leach lines/bed,spec al design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (131)
Seepage Pit
Maximum
Other:
Applicable
49f
Total Depth
Allowable
Depth
W
N/A Overburden Factor.
❑ 5❑ 6'
#,
TD
Well Review Approved:<D" Permit#
Dart�ehi:F-'Y
Y
SIGNATURE Grading Plan Approved:- Date:
J.' SIGNATURE
Plan Check Only Approved:
w
.,D[ate:
REMAR�S: n/.37tb� ��i �%t ttJ!li�G f1•4111 / _.Ii4 4,olT1 4o`
e/ew A
Ct%1}lf A'►'v G� +�5 t.' d / / �E.P @t? c1:
wry. ,r7��
'14Cd r�S d+ l� rAA? .c A 40
J�'T,i1�' A •,It rn
This application is APPROVEDGUENIED for the category checked.in
SECTION B above, regarding the design of a disposal system as indicated'
on the accompanied plot plan, using the requirements set forth in SECTION
C g
above. A-buildi permit is necessary for the installation of the above-
Revenue Code" Fee $
designed system. No construction is permitted in the required reserved
100% expansion area.
Z,
Check # '
(1) Septic Tank must be 1/Ominimum from any wells.
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(2) Leach lines must be 100minimum from any wells, including expansion
Date, Initial
O
area.
(~j
(3) Sewer lines must be 50' minimum f 6 any wells.
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(4) Seepage pits must be 150' minimum from any, wells, including expansion
RIVERSIDE: 909-955-8986
area
4\_t
INDIO' 760-863-7000
Signature
SOUTHWEST.909=600=6180
Date
nFH-'AN-122'Rev
81011 -
Distribution: WHITE=Office File;NELLOW—Applicant; PINK —Bldg. Dept.; GOLDENROD—Plans/Records
Certificate of Occupancy(TEMPORARY)
V Ot
-
G 19KMwS Building& Safet Department
OF
T9 Y p
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: 78-935 HIGHWAY III
Use classification: COMMERCIAL
Occupancy Group: M
Owner of Building: TARGET CORP
Building O cial
Type of Construction: VN-SPRINKLED
Building Permit No.: 0304-032
Land Use Zone: CR
Address: 1000 NICOLLETT MALL
City, ST, ZIP: MINNEAPOLIS, MO 55403
By: KIRK KIRKLAND
Date: 2-25-2004/EXPIRES 3-25-2004