RC (04-4792)78015 Main St Ste 204
04-4792
BUILDING & SAFETY DEPARTMENT
.0. Box 1504 (760).777-7012
8-495 CALLE TAMPICO FAX (760) 777-7011
A QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number04_-_00004792 Date 6/09/04
Property Address .. . . . . . 78015
MAIN ST STE 204
APN: .770-121-003- - -
Application description . . . REMODEL - COMMERCIAL.
.Property Zoning . . . . . . . VILLAGE COMMERCIAL
Application valuation
60,00
Owner
Contractor
----------------
OLD TOWN LA QUINTA
NUNGARAY, PETE
.78080 CALLE ESTADO #200
48640 CASABLANCA
STREET
LA QUINTA CA
INDIO
CA 92201
LA QUINTA CA 92253
(760) 564-0649
WCC: EXEMPT
WC: EXEMPT
11/30/05
CSLB: 389982
05/31/06
CCC: B
Permit BUILDING.PERMIT
Additional.desc
Permit Fee 81.'00
Plan Check Fee
52.65
Issue Date . . . .
Valuation
6000
Expiration Date 12/0.7/04
Qty Unit Charge Per
Extension
BASE FEE
y= 45.00
4.00 9.0000. THOU BLDG 2,001-25,000
----------
36.00
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Special Notes and Comments
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w
INSTALL TWO INTERIOR OFFICE'DIVIDER
WALLS.
Fee summary Charged Paid Credited-
- ------- - - - - - - - ------ - - - - ----'-- - - - - ------ - - -
---
.Permit Fee Total 81.00 .00 .06:.
Plan Check Total 52.65 .00 '.00
Grand Total 133.65 .00. ` ..00'`{
Due
81.00
52.65
133.65
P.O. BOX
78-495 CALLLLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: _04- 47Q;Z
Applicant:
Applicant's Mailing Address:
o
BUILDING PERMIT DECLARATIONS
I hereby affirm under penaltyof LICENSED CONTRACTOR'S DECLARATION
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 Class
Q _ ► L No. 1 L
- Date 4.7 ontractor {/
I herebyaffirm under OWNER 8 ILDER DEC TION
penalty of perjury that I am exempt from the Contractors' State License aw for the following reason (Sec. 7031.5, Business and Professans Code: Any
city or county that requires a permit to construct. after, improve, demolish, or repair any structure, prior to its issuance. also
requires
statement that he or she is licensed pursuant to the provisions of the Contractors* State License Law (Chapter 9 (commence g with Section 7000) of Dtivisiioon 3rtotf the Business
ess
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 improvefor 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 properly who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
am exempt under Sec. , B.3 P.C. for this reason
BUILDING & SAFETY DEPARTMENT
Architect or Engineer:
VOICE (760) 777.701:
FAX (760) 777-7011
INSPECTIONS (760) 777-715?
Date:
rvurnteci or tnglneer's Address:
Lic. No.
Date • Owner
I hereby affirm under penaltyof WORKERS' COMPENSATION DECLARATION
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 and policy number are:
Carrier Policy Number
I certify that, in the performance of the work for which this permit is issued. I shall not employ an workers, to ths
compensation laws of California, and agree that, if I should become subject to the workers' compensation Provisionsmro Saectionb3700 of t me bor Code, I shall
forthwith comply with those provisions.
1! - q-oy
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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
g gency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
IMPORTANT APPLICANT ACKNOWLEDGEMENT
Application ii hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions Bet forth on this application.
I. 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, indemnity and hold harmless the City of
2
officers. agents and employees for any act or omission related to the work being performed under or following issuance of this permit. La Quints, its
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.
Ice" 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 buildin0
construction, and hereby authorize representatives of this county to enter upon t above-mentioned property for inspection purposes.
I1 ` i nature
9 (Applicant or Agent):