10-0821 (PLBG)'P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4'(t 4 4v 4"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/31/10
Application Number: 10-00000821
Owner:
Property Address: 79485 HIGHWAY 111 STE 2
STAMKO DEV CO
APN: 600-020-027- - -
10345 W OLYMPIC BLV 2 FL
Application description: PLUMBING
LOS ANGELES, CA 90064
Property Zoning: REGIONAL COMMERCIAL
-----------------------------
Application valuation: 280
D
4
Contractor:
Applicant: Architect or Engineer:
Owner
AVG
p--------------------------
-----CF
r.
-------------------------------------------------------------------------------------------------
LICENSED CONTRACTOR'S DECLARATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: License No.:
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued.
Date: Contractor:
_ 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
OWNER -BUILDER DECLARATION
insurance carrier and policy number are: ,
I hereby affirm under penalty of perjury that I am exempt from the Contractor's State License Law for the
Carrier Policy Number
following reason (Sec. 7031 .5, Business and Professions Code: Any city or county that requires a permit to
OCI certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agreethat, if I s trtd' ecome subject to the workers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
X700 of the Labor ode shall forthwith r pl r ith those provisions.
that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by
111�i
applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•:
11tateC& Applicant:
QQ 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
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION d0R.1,12 IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the -
DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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 contractor(s) licensed
pursuant to the Contractors' State' rise Law.l.
(_ 1 I am exempt under Sec. ale.&P. for this reason
/U /Owner:
CONSTRUCTION LENDING AGENCY .—
I
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: ` 1
Lender's Address: 1�+
r
LQPERMIT
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 aresult 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.
Icertify that I have read this application and state that the ab information is c I agree to comply with all
city and county ordinances and state laws relating to build' g con ruction, an ereby out 'ze representatives
D�of /isIcount to nter upon the above-mentioned prop rty r ' pection pur ses.
V gnature (Applicant or Agantl:
Application Number
10-00000821
Permit . . . PLUMBING
Additional desc .
Permit Fee . . . . 42.00
Plan Check
Fee
10.50
Issue Date . . . .
Valuation
0
Expiration Date 2/27/11
Qty Unit Charge Per
Extension
BASE
FEE
15:00
4.00 6.0000 EA PLB
FIXTURE
24.00
1.00 3.0000 EA PLB
WATER INST/ALT/REP
------------------
3.00
---------------------------------------------------------
Special Notes and Comments
INSTALL NEW WATER SERVICE AND 4
SINKS.
2007 CODES.
----------------------------------------------------------------------------
Other Fees . . . . . . . . .
BLDG STDS ADMIN (SB1473)
1.00
Fee summary Charged
----------
Paid Credited
------------------------------
Due
-----------------
Permit Fee Total 42.00
.00
.00
42.00
Plan Check Total 10.50
.00
.00
10.50
Other Fee Total 1.00
:00
.00
1.00
Grand Total 53.50
.00
.00
53.50
LQPERMIT
°FEW
P.O. Box 1504
LA QUINTA, CALIFORNIA -92247-1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
PROPERTY, OVMER'S PACKAGE
(760) 777-7012
FAX (760) 777-7011
Disclosures & Porins for Owner -Builders Applying for Construction Permits
FJ, ORT, NT.! NOTE 1F T )1'R 'PRiZTY (1y�j i
R(W Property Owner
A n application for a building permit has been submitted in your name listing yourself as the builder of the Property
ig*Gvements specified at
'V'enre providing you vxith an Owner -Builder A€lmowiedgnmt.and. Information Veri€catim Form to make you awatsa:o€your
rr sibalities and possible risk }you may incur by halving U&permit-issued.in your nameas the
Oma -Builder. We will not Issue a bullding.permit until you lave read, Inidalod your understanding of ea&pmAsion,
Zsigned, and returned this form to us at our official address indicated. An agent of the owner cannot execute this': -notice
less You, the property owner, obtain the prior approval of the permitting authority.
K• Read art¢Odliaf eft:swwftmrb vv Wsignify you wtdw-stand or, vero tkis eRfbrm adon.
understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -Builder"
b ding permit that erroneously implies that the property owner is providing his. or her own labor and material pers6naft_ I, as
an Owner -Builder, may be held liable and subject to serious financiat'risk for any injuries sustained by an unlicensed person
and his or her employees while working on my property. 'My homeowner's insurance may not provide coverage for those
int'"Aes• 1 am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers
-o1r9y piny.
2. I understand building permits are not required to be signed by property owners unless they are responsible for the
traction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect
if from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my
own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on
i
its and contracts.
S.1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value
y construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employee'
under state and federal law.
Kovec
understand if I am considered an "employer" under state, and federal taw, I must register with the state and federal
ent, withhold payroll taxes, provide workers, compensation disability insurance, and' contribute to unemployment
compensatioh for each "employee." I also understand my failure to abide by these laws may subject me to serious financial
risk.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential
s trines cannot .legally build them with the .intent to offer them for sale, unless all work is performed by licensed
subcoontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be beld liable for any
financial or personal. iujgnes sustained by any subsequent owner(s) that result from any latent contrition defects in the
workmanship or materials.
9. I understand I may obtain more information regarding my obligations as an "employer" frown the blernal Revenue
Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California
Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (C3LH) at 1-
800-321-CSLB (2752) or www.cslb.ca gov for more information about licensed contractors.
10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party legally and financially responsible for proposed construction activity at the following address:
I L 1. agree that, as the party legally and financially responsible for this proposed construction activity, .1 will abide by all
applicable laws and requirements that govern Owner=Builders as well 8 employers.
12. 1 agree to notify the issuer of this form immediately of any additions; deletions, or chouged to any of the informetim 1
have provided on this form Licensed contractors are regulated by laws designed to protect the public. If you contract with
somaane who does not have a license, the Contractors' State License Board may be unable to xmM you with any finamoint loss
you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may ba in,civil court It is also
important for you to understand that if an unlicensed Contractor or employee of that individual or fim.is injured while v oddag
on your Property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hkc CorruEraetors,
You will be responsible for verifft whethm or not those Contractors are properly ticensed and tee status of their waikers'
eompensation insurance coverage.
Before a building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issuft Ma permit, Mots; A.copy. of dw property owner's Mver'stbrtse� farrrr riots dvnr or
other verification acceptable to the agency is Wired to be presented when thep¢..rttdt is iars W to verify the property
owner's signature. '
Signature of P Date:
Note: The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZATION OF AGENT TO ACT ON ]PROPERTY OWNEH'S M_H_6 _,F
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize
the following persons) to act as my agent(;) to apply for, sign;. and file the documents necessary. to obtain an Owner -Builder
Permit for my project. A�
Scope of Construction Project (or Description of Work):
Project Location or Address: &(/C(r C
Name of Authorized Agent: '-1M A,4_k, J /. / �Q /t� Tel No
Address of Authorized Agent:
I declare under penalty of perjurythat 1 am the property owner for the address listed above and I personally filled out the above
information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification
acceptable to the agency is required w be presented when the permit is issued to verify the property owner's sighature..
Property Owner's Signature: Date:
RIVERSIDE COUNTY FIRE DEPARTMENT
• �:.... FIRE PROTECTION PLANNING SECTION
t, FIRE & LIFE SAFETY NOTICE
Inspection Date: Inspection Time: Occupancy Class:
Inspected By: A Phone 0 ~% -
Facility Name: ( �'•+ : '
Site Address: 'A -q
Owner/Contact Name:%6
Facility Phone: ( )
City: �,C( �� ,� { l Stater Zip:
Contact Phone: Fax: ( )_
Mailing Address: nVj al =e City: State: Zip•
Request / Received Date Signature of Recipien -_. a j C_, ,,
t
At this time a -notice was issued indicating the corrections required to provide compliance wit�ic
h the applicable codes, regulation m4ordies. All items shall be
corrected IMMEDIATELY. If you have any questions regarding this information, please contact the Riverside County Fire Department at (760) 863-8886
PREMISES IDENTIFICATION
Numbers plainly visible and legible. (CFC 505.1)
KNOX ACCESS
Knox access at Gate and Main Door. (CFC 506.1)
EMERGENCY INFORMATION
Emergency Information (CFC 404.2)
HYDRANT, -FDC, P1V
_ Caps missing. (CFC 508.5.2, 912.6)
_ Obstructions. (CFC 508.5.4)
lue Dots. (RCoStandard)
Signage: ( CFC 510.1)
FIRE APPARATUS ACCESS ROADS
_ Red -durb or signs. (CFC 503.3)
Obstructions (Width 20', Vertical 13'6"). (CFC 503.2.1)
FIRE EXTINGUISHERS
_ Minimum 2A IOBC. (CFC 906.3)
Servicing due. (CFC 906.2) }
Mounting <5 feet from floor. (CFC 906.9)
_ Obstructions. (CFC 906.6)
Commercial kitchen. (CFC 904.11.5)
FIRE ALARM
_ Serviced (CFC 907.20.5)
FACP Room Signage (CFC 510.1).
AUTOMATIC FIRE SPRINKLER SYSTEMS
5 yr. riser/sprinkler servicing. (NFPA 25, Table.5.1)
18" clearapce below sprinkler head deflectors. (CFC 315.2.1)
.spectors valve test. (NFPA 13)
t S rinkler wrench. (NFPA 13)
12 spare sprinkler heads. (NFPA 13)
✓✓ Missing escutcheon. (NFPA 13)
Riser Room Signage (CFC 510.1)
HOOD AND DUCT'SYSTEMS
_ Service with in 6 months. (CFC 904.11.6.4)
_ Proper nozzle position, caps, coverage. (NFPA 25, 10.2.5.3)
_ Fusible links, cables, conduits. (CFC 904.11.6.5)
Filters/ducts clean. (CFC 904.11.6.3)
FLAMMABLE LIQUIDS (CLASS 1, II, H -A)
Approved safety cans. (CF4t 3404.3.1.1)
Approved cabinets exceeding 10 gals. (CFC 3404.3.4.4)
_ Legible labeling. (CFC 3403.5)
_ Placard/NFPA 704 (CFC 3404.2:3.1)
Secondary Containment (CFC 3405.3.7.5.3)
GENERAL HOUSEKEEPING
_ Rubbish/trash buildup. (CFC 304.1)
_Secure pressurized cylinders. (CFC 3003.5.3)
_ Clearance around water heater. (CFC 305.1)
_ Storage not within 24 inches ceiling. (CFC 315.2.1)
_ Storage under stairs prohibited. (CFC)
Storage, use and handling of combustible materials in attic, under floor &
concealed spaces. (CFC 315.2.4)
_ Storage in boiler rooms, mechanical rooms or electrical equipment rooms
not allowed. (CFC 315.2.3)
WALLS AND CEILING
_ Holes in fire rated walls sealed. (CFC 703.1)
Tiles in fire rated ceilings in place and undamaged. (CFC 703.1)
EXITS
_ Common knowledge hardware. (CFC 1008.1.8)
Sign above door stating "This Door To Remain Unlocked When Business Is
Occupied. (CFC 1008.1.8.3)
_ Illuminated EXIT sign(s) operable. (CFC 1028.4)
_ 44" clear access width to exits. (CBC)
Exit obstruction. (CFC 1028.3)
_ Maintain fire rated doors, windows, dampers and hardware. (OFC 703.1)
_ Emergency lighting operable. (CFC )
Panic hardware operable. (CFC 1008.1.9)
OCCUPANT LIMIT/SIGN
Occupant load sign(s) posted. (CFC 1004.3)
Required NO SMOKING signs. (CFC 310.3)
ELECTRICAL
_ Multiplug adapters not allowed. (CFC 605.4)
_ Circuit breaker panel — Clear and labeled. (CFC 605.3)
_ Abatement of electrical hazards. (CFC 605.1)
_ Extension cords not allowed as permanent wiring. (CFC 605.5)
_ Outlet faceplate/covers in place. (CFC 605.6)
Comments:
Bin #
City of La Quinta
Building U Safety Division'
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit # A
i'
�D
Project Address: �� .. L
er's Name:
A. P. Number:
Address:
Legal Description: •
Address:
City, ST, Zip:
Telephone:r s
Project Description:
City, ST, Zip:
Telephone:
Eaty
State Lic. ##;
Arch., Engr., Designer.
Address:
City., ST, Zip:
Telephone:A<„£at.
•'
<•<Y'
State Lic. #: ' ”. M o
Name of Contact Person: -
Construction Type: Occupancy:
P cy:
Project type (circle one): New Add`n Alter Repair Demo
Sq. FL:
# Stories: T#Units:A
Telephone # of Contact Person: `" ,— `7 �,
Estimated Value of Project:. Z — • da
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
ltec'd
TRACMG
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs
Reviewed, ready for corrections
Plan Check Deposit
Truss Caics•
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plins resubmitted
Grading
IN HOUSE:-
3 "Review, ready for correctionsfissue
Developer Impact Fee
Planning Approval
Called Contact Person
A,I,P,P,
Pub. Wks. Appr
Date of permit issue
School Fees
I�
Total Permit Fees
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