05-0303 (CSCS)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Y Application Number:
Property. Address:
APN:
Application description
Property Zoning:
Application valuation:
Applicant:
0�_5 00000303
79174 HIGHWAY 111
G49 -820 -999 -
NEW COMML - STORES &
REGIONAL COMMERCIAL
458118
Tiht °F 4Quz«tw
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
CUSTOMER SERVICE
Architect or Engineer:
Quilt
LA ------------------------------------C�ANCE�EPT.
. LICENSED CONTRACTOR'S DECLARATI
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 rofessionals Code, and my License is in full force and effect.
License Cl ss: B Licen lo.: 572657
Date:�� Contractor54OWN
-BUILDER DECLARATION
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, 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 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 1$500).:
(_) 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 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.).
(_ ) 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:
LQPERAIIT
Owner:
FOURTH QUARTER PROPERTIES
45 ANSLEY DR
NEWNAN, GA 30263
(760)613-3783
Contractor:
VRATSINAS CONSTRUCTION CO.
P.O. BOX 2558
LITTLE ROCK, AR 72203
(501)376-0017
�Al Lic. No.: 572657
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10/28/05
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 ZURICH INS Policy Number WC531636300
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 be me subject to the workers' compensation provisions of Section
3700 of the Labor Code, all forthwith comply wi t .seerp_rovisions.
Wale: p �) Applicar�l/
WARN G: FAILURE TO SECUR ERS' COM NSATI 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.
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 i mation is correct. I agree to comply with all
city and county ordinances and state laws relating to building [ruction, and hereby au orize representatives
of this coun y t enter upon the above-mentioned property r inspection purposes
gdte: ro Signature (Applicant or A nt):�� S
Application Number .
. . . . 05-00000303
Permit
BUILDING PERMIT
Additional desc .
Permit Fee . . :
1896.00
Plan Check Fee
1232.40
Issue Date . . . .
Valuation
458118
*? Expiration Date
4/26/06
t
Qty Unit Charge
Per
Extension
BASE
FEE
639.50
359.00 3.5000
THOU BLDG
100,001-500,000
1256.50
Permit . .
ELEC-NEW COMMERCIAL
Additional desc .
Permit Fee
195.60
Plan Check Fee
48.90
Issue Date . . . .
Valuation . . . .
.0
Expiration Date
4/26/06
Qty Unit Charge
Per
Extension
BASE
FEE
15.00
9030.00 .0200
--------=-------------------------------------------------------------------
ELEC
GARAGE OR NON-RESIDENTIAL
180.60
Permit . . .
GRADING PERMIT
Additional desc .
Permit Fee . . . .
15.00
Plan Check Fee
.00
Issue Date . . . .
Valuation . . . .
0
Expiration Date
4/26/06
Qty Unit Charge
Per
Extension
----------------------------------------------------------------------------
BASE
FEE
15.00
Permit . ...
MECHANICAL
Additional desc . .
Permit Fee . . . .
123.00
Plan Check Fee
30.75
..Issue Date . . . .
Valuation . . .'.
0
Expiration Date
4/26/06
Qty Unit Charge
Per
Extension
BASE
FEE
15.00
6.00 9.0000
EA MECH
FURNACE <=100K
54.00
6.00 9.0000
----------------------------------------------------------------------------
EA MECH
B/C <=3HP/100K BTU
54.00
Permit . . . . .
PLUMBING
Additional desc .
Permit Fee . . . .
42.00
Plan Check Fee
10.50
LQPERD)1IT
Application Number . . . . 05-00000303
Permit PLUMBING.
Issue Date . . . . Valuation 0
Expiration Date 4/26/06
Qty Unit Charge Per Extension
BASE FEE 15.00
4.00 6.0000 EA PLB ROOF DRAIN 24.00
1.00 3.0000 EA PLB WATER INST/ALT/REP 3.00
----------------------------------------------------------------------------
,' Special Notes and Comments
9030 SQ. FT. SHELL BUILDING ONLY (PAD
3). June 10, 2005 1:28:47 PM JJOHNSON
•------------------------------------------------------------------------- --
Other Fees ART IN PUBLIC PLACES -COM 2270.59
DIF CIVIC CENTER - COMM 857.85
ENERGY REVIEW FEE 123.24
DIF FIRE PROTECTION -COMM 288.96
STRONG MOTION (SMI) - COM 96.20
DIF STREET MAINT FAC -COMM 207.69
DIF TRANSPORTATION - COMM 15567.72
Fee summary Charged Paid Credited Due
----------------- ---------- ----- - ---- ---------- ----------
Permit Fee Total 2271.60 .00 .00 2271.60
Plan Check Total 1322.55 900.00 .00 422.55
Other Fee Total 19412.25 .00 .00 19412.25
Grand Total 23006.40 900.00 .00 22106.40
L&EPWIT