RC (0309-307)78015 Main St Ste 111
0309-307
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
771883 B 11/30/2(
Date 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&RC. 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 STATE FUND Policy No. 1440125-03
(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.
Date: 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 laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT# rG
f
0309-307_95
DATE VALUATION LOT
$12,250.00
JOB SITE
APN
ADDRESS 7s -on MAIN sTRLL r SUITE 111
- -
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
OLD TOWN LA QUINTA LLC
b& RVIN HOMES
78.080 CALLE ESTADO SUITE 201
78-080 CALLE ES'TADO STE 201
LA QUINTA CA 92253
L -QUINTA CA 92253
(760)771=2567 CBL9 5407
USE OF PERMIT
COMMERCIAL REMODEL
COMMERCIAL REMODEL (MERCANTILE SPACE TI) 2001 CBC, 1225 S.F.
"M° OCCUPANCY, TYPE VN SPRINKLED, OCCUPANT LOAD 41
VALUATION 12,230.00 LS
,
ESTIMATED COST OF CONSTRUCTION
12,250.00
PERMIT FEE SUA04ARY
PLAN CHECK FEE 101.000-439.318 $93.60
CONSTRUCTION FEE 101-000-418-000 $144.00
MECHANICAL FEE 101-000-421.000 $19.50
SUB TOTAL CONSTRUCTION AND PLAN CF=
$257.10
LESS- PRE -PAID FEES
$0.00
TOTAL PEP= FEES DUE NOW
$257.10
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
FEB— 4-04 WED 5:29 PM RIV• CO; FIRE P&E INDIO FAX" H. 1 760 863 7072 P. I
t RIVERSIDE COUNTY FIRE DEPARTMENT
7n cooperation with the
p California Department of Forestry and Fire Protection
10 UU's• an aanto venue. ems, Ce ornta 70 • (909 ax ( 10
S
Board orsupervisors
Bob fluster,
Di.trict 1
John Tavagliane,
De>trict 2
Jim Venable,
District 3
Roy Wilson,
Distri t 4
Marion Ashley,
District 5
EMERGENCY SERVICES OMSION • PLAh KING SECTION • INDIO OFFICE
827675 Highway III, 2n" A., Indlo, CA 92201 (760) 863-8886 • Fax (760) 863 7072
•
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Tom Tisdalo:
Fire Chlef•
2004
February 4, ii
Proudly serving the
Unincolporatcd
Areas of Riverside
City Of La Quints
County and the
Building Department
Citic,; of: "
Re: Fire and Life Safety Clearance'
$2nfiing
Old Town La Quinta..
:•
" 13eautilolll
•`
Calinlcsa
The Riverside County Fire Department is granting a fire and life safety clearance for the
Following suites #106,109,111 located at 78015 Main st.-L"a=Quinta. Please call if you
Canyon Lake
should have any questions.
E.
Coachella
•
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Desert Hal Springs
G
•
FRANK KAWASAKI
Indio
Chief Fire Department Planner
G
,
Lakc Elsinore
G
Lz Quinta
By
O
Moreno valley
Terry DeSoucy
Fire Systems Inspectors
f._
Palm iA:sel1
G
Perris
G
,
Randio Mirage '
San Jacinto
C•
Tcniceula
Board orsupervisors
Bob fluster,
Di.trict 1
John Tavagliane,
De>trict 2
Jim Venable,
District 3
Roy Wilson,
Distri t 4
Marion Ashley,
District 5
EMERGENCY SERVICES OMSION • PLAh KING SECTION • INDIO OFFICE
827675 Highway III, 2n" A., Indlo, CA 92201 (760) 863-8886 • Fax (760) 863 7072
•
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