10-0113 (SIGN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4'ht
"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: 10-00000113
Owner:
Property Address: 78995 HIGHWAY 111 STE 6
WASHINGTON 111 LTD
APN: 643-020-056- - -
C/O JACK TARR Zf
Application description: SIGN
30240 RANCHO VIEJO RD. STE
Property Zoning: REGIONAL COMMERCIAL
SAN JUAN CAPISTRANO, CA 92
Application valuation: 2000
_ . _ _
Contractor:
Applicant: Architect of Engineer:
%).
SIGNARAMA
41945 BOARDWALK, "L"
PALM DESERT, CA 92211
(760)776-9907
Lic. No.: 830131
-----------------
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 fessionaqnse
my License is in full force and effect.
License Class: D42 C45 830131
Date: ON10" Contractor:
OWNER -BUILDER D LARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor'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, atter, 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 Contractor's 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).:
1 _ 1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and i
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 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.).
(_ 1 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 contractors) licensed
pursuant to the Contractors' State License Law.).
(_) I am exempt under Sec. B.&P.C. for this ieason
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
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 2/18/10
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 1938607
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 subj to the workers' mp ation provisions of Section
3700 of the LaborXCodhall forth th com ose p visions.
-Date:,Applicant:
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERA.G 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.
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 agr corn ly with all
city and county ordinances and state laws relating to building nstructio an by au ze repr natives
of this county to enter upon the above-mentioned propert f inspe rp
Date:' i� Signattu_re (Applicant or Agent):
Application Number . . . . . 10-00000113
Permit . . . .ELEC-ELECTRICAL SIGN
Additional desc .
Permit Fee . . 30.00 Plan Check
Fee
.00
Issue Date . .Valuation
0
Expiration Date . . 8/17/10
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 15.0000 EA ELEC SIGN 1ST CIRCUIT
15.00
-----------------------------------------------------------------------------
Special Notes and Comments
(1) ILLUMINATED CHANNELL LETTER SIGN PER
------ .___..__..__.._.._ SP 2010-1425 "ORIENT CUISINE"
----------------------------------------------------------------------------
Other Fees . . . . . . . . . BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged Paid Credited
Due
-----------------------------------------------
Permit Fee Total 30.00 .00
----------
.00
30.00
Plan Check Total .00 .00
.00
.00
Other Fee Total 1.00 .00
.00
1.00
Grand Total 31.00 .00
.00
31.00
LQPERMIT ..
Certificate of Complia
nce (Signin) (Page 1 of 2) SLTG-1C
v P; �t��t \ ai �� ase of Construction ❑ New Construction ❑ Addition ❑ Alteration
'I'vpc Outdoor Signs .,
Prosect Address: _ g ❑ Indoor Signs
tc:
C I
C,,� / omp tante Method Used ❑Maximum Allowed
} t k 1 �' 0U& Vl'�G\ 7f'J 21 5 f O Lighting Power ❑ Alternate Lighting Sources
Documentation Author's Declaration Statement
• 1 certify that this Certificate of Compliance documentation is accurate and complete.
\;une
Signature /
Companl. t.
Date
Address
L' n
I l�✓G,ll� �u. CEApicable:
_c
Citr`State-lip CEPS
�6/►1 r% Phone:
-2C� -
Principal Lighting Designer's Declaration Statement
• I am el ONO under Division 3 ofthe California Business and Professions Code to accept responsibility fir the lighting
design.
• This Certificate of Compliance identities the lighting features and performance specifications required for compliance ith
Title 24. Pages I and 6 of the Calif' rnia Code of' Regulations.
• The design features represented on this Certilicate of Compliance are consistent with the information provided to document
this deSi n on the other applicable compliance forms. \vorksheets, calculations, plans and specifications suhmitted to the
enforcement agency for approval with this building permit application.
\'.ones
Signaunc
CCumpam
\ddresc:
CiW,'Swte%Lip:
Sign Nlandatory Measures
X Indicate location on building plans of Mandatory Sign Measures Note Block:
Phone
License tf
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