05-3798 (RC)P.O. BOX 1504
78-495 CALLE TAMPICO
f LA QUINTA, CALIFORNIA 92253
r.
Application Number: X05:=00003L79_8_13i,,
Property Address: 78772 HIGHWAY 111
APN: 643-080-037-13 -000000-
Application description: REMODEL - COMMERCIAL
Property Zoning: REGIONAL COMMERCIAL Ilun
Application valuation: 1200
Applicant:
Architect or Engine
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT .
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/26/05
Owner:,
ONE ELEVEN LA QUINTA
C/O SABBY JONATHAN
- 42620 CAROLINE CT STE 102
0� PALM DESERT, CA 92211
AUG 2 O 2005 Contractor:
CONSOLIDATED CONTRACTING, INC.
CITY OFLAQU�NTA 46753 ADAMS STREET
WYOFLAQUININMCE . LA QUINTA, CA 92253
(760)771-3345
LiC. No.. 824183
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 Pr essionals Code, and my License is in full force and effect.
License Class-. C8 Licen a No.: 824183
Date ontractor: �+
OWNER -BUILDER DE RATION
I hereby affirm under penalty of perjury that I am exempt from the C tractor's 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 i issuance, also requires the applicant for the
permit to file a signed statement that he or she is licensed pursuant the provisions of the Contractor's State
License Law (Chapter 9 (commencing with Section 7000) of Divisi 3 of the Business and Professions Code) or
that he or sheds exempt therefrom and the basis for the alleged axe ption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil penalty of of more than five hundred dollars ($500).:
( 1 I, as owner of the property, or my employees with wages as heir sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 704 , 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 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.).
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.). -
(_ 1 I am exempt under Sec. , BAP.C. for this reason
Date:
Owner:
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:
LQPERMIT
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 and policy number are:
Carrier STATE FUND Policy Number 1770749-2005
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.49camm subject to the workers' compensation provisions of Section
700 of the Labor Co , s II f rthwith c ly with those provisions.
•i&& -Applicant:
WAR NG: AILURE TO SECURE WORKERS' COMPENSATI N COVERAGE IS UNLAWFUL, AND SHALL
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND Cl IL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS 1$100,000). IN ADDITION TO THE COST OF CO PENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND A RNEY'S FEES.
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 Ouinta, 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 information is correct. I agree to comply with all
city and county ordinances and state laws relating to bu' d' ruction, d he
authorize representatives
of thisqq//�uu/,-nty ent r upon the above-mentioned grope tion rp ses.
Dated /VSignature IAPPlicant or Agent) }
Application Number . . . . . 05-00003798
Permit . . . BUILDING PERMIT
Additional desc .
Permit Fee . . . . 29.00 Plan Check
Fee
18.85
Issue Date . . . . Valuation
1200
Expiration Date 2/22/06
Qty Unit Charge Per
Extension
BASE FEE
15.00
7.00 2.0000 HND BLDG 501-2,000
----------------------------------------------------------------------------
14.00
Permit . . MECHANICAL
Additional desc .
Permit Fee . . . . 24.00 Plan Check
Fee
6.00
Issue Date . . . . Valuation
. . .
. 0
Expiration Date 2/22/06
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 9.0000 EA MECH APPL REP/ALT/ADD
9.00
----------------------------------------------"------------------------------
Special Notes and Comments
RELOCATE BOILER FROM MECH ROOM TO
EXTERIOR(MODEL HRN, EXTERIOR USE). 24
LF 6' BLOCK WALL PER CITY STANDARD
Fee summary Charged Paid Credited
----------------------------------------
Due
-----------------
Permit Fee Total 53.00 .00
.00
53.00
P1an.Check Total 24.85 .00
.00
24.85
Grand Total 77.85 .00
.00
77.85
LQPERMIT � - .� � •. _ �Ot C ' �� F/ ��%ia f�R � S � R��1_ C� �l� /� �,iT✓� �.
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