04-5992 (RC)L°� U i
®� WAC)"A C9 n
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
Application Number . .
. . . 04-00005992
Date
9/01/04
Property Address
77985 AVENIDA MONTEZUMA
APN:
773-104-036-24 -000000-
Application description
. . . REMODEL - COMMERCIAL
Property Zoning . . . .
. . . VILLAGE COMMERCIAL
Application valuation
10000
Owner
Contractor
NEWELL INVESTMENT
SCRIVENS CONSTR,
INC.,
G.L.
P 0 BOX 1574
61400 YUCCA ROAD
LA QUINTA CA
92253 MOUNTAIN CENTER
CA 92561
(760) 349-3327
WCC: STATE FUND
WC: 807645
01/01/05
CSLB: 807645
05/31/06
CCC: B
------ Structure Information
REMODEL CANOPY OVER GAS PUMPS
-----
Construction Type . . .
. . TYPE V - 1 HR
Occupancy Type . . . .
. . HIGH FIRE OR PHY HAZMAT
Flood Zone . . . . . .
. . NON -AO FLOOD ZONE
Other struct info . . .
. . CODE EDITION
2001
FIRE SPRINKLERS
NO
------------------------------------------------------------
Permit . . . . . . BUILDING
PERMIT
----------------
Additional desc
Permit Fee . . . .
117.00 Plan Check Fee.
76.05
Issue Date
Valuation . .
. .
10000
Qty Unit Charge Per
-
Extension.
BASE FEE
45.00\
8.00 9:0000 THOU
-------------------------------'---------------------------------------------
BLDG 2,001-25,000,
72.00
Special Notes and Comments
ERMODEL CANOPY OVER GAS
PUMPS.
Fee summary, Charged
----------------- ----------
Permit Fee Total 117.00
Plan Check Total 76.05
Grand Total 193.05
Paid Credited Due
---------- ---------- ----------
.00 .00 117.00
.00 .00 76.05
.00 .00 193.05
P.O. BOX 1504 • �i .
w VOCE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: O 14— 5 9 9— I Date: 'i' z
Applicant: /
Applicant's Mailing Address: '
G#t 92-5-6
Architect or Engineer:
Architect or Enggineer's Address:
/4 2 G aa.. �/� .�: /%cJ z4i G
Lic. No. 7
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 igjp full force and effect. L� 7
License Class : License No. - Fv.? 6
Date �F 2— -yContractor (� - ��—�i ✓ E�'vs� ��
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she 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 five hundred dollars ($500).):
U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the 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 or she did not build or improve for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. , BA P.C. for this reason
Date
WORKERS' 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
iss ed. My worke 'compensation insurance carrier and olicy number are:
Carrier S 4- ! Policy Number d i
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 provisi
c/�� pl
Date / G a / Applicant
WARNING: FAILURE TO SECURE WORKERS' CO NSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 informati 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 county to e r on the above t' ed property for inspection purposes.
Date Signature (Applicant or Agent):
X
x
A
X
wmtati.b.
Bin#
Permit #
5 C
City of La Quinta
BuildingSafety aL DlVlslon
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Project Address:
A. P. Number:
_
S7 /1-101vTt2vA-&-f
Otimer's Name: �JLo� /� /ul/P At
Address: po/3 / S`7 f Ta'e-
Legal Description:
City. ST. Zip:
Contractor:G
FTelephone: 7 o j6
Address:
1XProject Description:
City, ST, Zip:
Telephone:
._br7
State Lic. # : 07
Arch., Engr., Designer:
City Lic. #: a
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:
>skY".' ; ;:'" "y, .' ,
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: # St es: T# Units.
Telephone # of Contact Person: 66 8 " �1n6
stimatcd Value of Projec 7% Oti j
APPLICANT:
DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cates.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Cates.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontaetor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
3' Review, readv for correctionstiissue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
8�
Total Permit Fees
B � VU
Tom Tisdale
Fire Chief
Proudly serving the
unincorporated
areas of Riverside
County and the
Cities of:
Banning
ee
Beaumont
Cahmesa
Canyon Lake
Coachella
Desert Hot Springs
Indian Wells
Indio
Lake Elsinore
La Quinta
Moreno Valley
Palm Desert
Perris
Rancho Mirage
San Jacinto
Temecula
Board of Supervisors
Bob Buster,
District 1
John Tavaglione,
District 2
Jim Venable,
District 3
Roy Wilson,
- District 4
RIVERSIDE COUNTY
FIRE DEPARTMENT
In cooperation with the
California Department of Forestry and Fire Protection
210 West San Jacinto Avenue • Perris, California 92570 • (909) 940-6900 • Fax (909) 940-6910
December 22, 2004
To: La Quinta Building Department
Re: Final fire Clearance
The Riverside County Fire Department is granting a fire life safety clearance for
# LAQ-04-BP-064 / Village Gas Station 77-985 Avenida Montezuma
If you have any questions contact me at 760-345-6954
Respectfully,
Neal Stephenson
Fire Systems Inspector
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE i—
SUBJECT/ t q aQ .
��t" <^. PERMIT NO.
ADDRESS 711 � ? 1 X u e_ .� t/l/�C,n to
REMARKS:
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COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE 12-
SUBJECTVi-�('� PERMIT NO.
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INSPECTOR
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DEH -SAN -118 (Rev 8/02) Distribution: WHITE—Office; CANARY—Owner; PINK—Office
DEH-SAN-118(Rev &02)
Distribution: WHITE -0 ffice; CANARY—Owner; PINK—Office
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY
-DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
SUPPLEMENTAL REPORT TO SAN. FORM # DATE
SUBJECT
PERMIT NO.
ADDRESS
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f7r• - -P.-, 70
INSPECTOR
REMARKS:
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Distribution: WHITE -0 ffice; CANARY—Owner; PINK—Office
,- Certificate of Occupancy
4 40"
G� OF'TBuilding & 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: 77-985 AVENIDA MONTEZUMA
514 Z
Use classification: COMMERCIAL Building Permit No.: 04 -
Occupancy Group: M Type of Construction: V-1 HR Land Use Zone: CC
Owner of Building: NEWELL INVESTMENT Address: PO BOX 1574
City, ST, ZIP: LA QUINTA CA 92247
By: KIRK KIRKLAND
Date: 3-16-05
Building Official
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