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0007-071 (PC)LICENSED CONTRACTOR 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 Professionals Code, and my License is in full force and effect. Liccncc # Lic. Class Exp. Date Date Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: 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 & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code).` "/ �` ( ) • I arra. exempt nder pg ion B&P.0%for this reas n Date�C� B Signature of Owner �"�' 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' cbtnpensation, 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 & policy no. are: Cartier Policy No. (This section need not be completed if;the permit valuation is for $100.00 or less). () I certify that in the performance of the work for which this permit is issued, I shall not employ any persoh"iln any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section`370,0,1/of the Labor Code, jfshd forthwith comply with those ptoVislons. .✓ i — Warnngc" Failure to secure Wor�CeF9-Compensation coveraie is,�unlawful and shall subject an employer to criminal penalties and civil fines Up' $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for.whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify.that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws,relating to the.building construction, and hereby authorizeyepresentatives of this City to enter upon the above-mentioned property or inspection urp `ses. �. Signature (Owner/Agent) + i �m,� Date" {� BUILDING PERMIT PERMIT# <a DATE VALUATION LOT '�_,'�'$ 4RACT JOB SITE APN ADDRESS 79-490 q -p p' wtyYY OWNER CONTRACTOR / DESIGNER / EN (NEER Pik.'C.,lSAD ' A.'; & W,,AS1 I, 19C OWURR PlunIM( 30-10) tWOTY-RA CT, MD :Atad:Pf;3RAIiIY.:,rL„a CA 91 301 USE OF PERMIT S.UC•S�l,I8�9:F�i.:L: ;4360 V OAS 5i"ra' TION CAINOP"Y OHM A1.111kc."19D PLANS alfily CONTRACTAMOUNT NT AS�J�a." W 4 Ca9STRUCTION FF& 101 "M-416 000 $01150 101-000-4,39-:318 $4119S Y1,312011`i'1:iICAA, PER 101-000,420-000 "1.170 i?J_'iROTS 91140 MIN 1.01.000,4 t 9-000 $42.0 $'j'ROl` O j!,A.OTION WT, • COMM.. 100-000-241-000 S111%.0 0R,in'f, .140 ME 101-1009•423-0W W-00 j;3EV,91-OH"R IMPACT FFR 01713.12 f:T lE& PUBLIC PLACES - COm`�13Y-a`?t3(B f P:w1 cyn CO3 6(_'0014 .�.L4:i�C-PiyI:7.�1A�w�[`�€a'I' �Cp y1�Cp��, L�.'Q��'9 I ) rrJ.�f"las 1S�Y,1:.Y-,i .'�A.{d.P ITSFIS bb" 1Q6l. iJil J U L -6- 2001 T .. UJRT VT UUP SOW CITY OF LA OUINTA FINANCE DEPT RECEIPT DATE_, j BY . ��h G,P DATE FINALED INSPECTOR INSPECTION RECORD-` OPERATION DATE INSPECTOR OPERATION DATE, INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts, Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck p Exhaust Fans O.K. to Wrap F.A.U. Framing �� , V_Z Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 -Controls .• Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath ti Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs �. Electric Bond Footings Main Drain 'Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral . Pool Cover Sewer Connection . Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: K +� Final _ Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring W'ixtures Main Service jub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) J OWNER / BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. i If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing 'their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, 92253 (7X0) 72 �� FAX -0-0777-70W OWNER'S SIGNATURE/ PROPERTY ADDRESS 00o:2 - 0 PERMIT NI BER(s) atFRI 1053 AM RIY, CO, FIRE PSE INDIO Tom Tisdale Fire Chid Proudly serving the unincorporated areas of Riverside county kad the Citics of. Baftning v Beaumont Cattyo11 Lake Goscliclla lhscrt clot Springs Indian weus 1 Indio e• Lakc Elsinore IA C�uiltla Morctlo valley Palm Des -.rt Penis r,. Rancho Mirage :• Sail Jacinto Tenlccula Board of Supervisors Bob Buwt, District I John Tavarlione, District 2 Jinn Venable, District 3 Roy Wilson, District 4 Tom Mullen, District S y i FAQ: NO, 1 760 363 7072 P. 2 RIVERSIDE COUNTY FIDE DEPARTMENT In cooperation with the California Depctrtmenr of Forestry and Fire Protection 210,West San JacintoAventle • Perns. a ornia • • Fax (909) 940-6910 4 June 29, 2001 To: City of La Qulnta Building Department Re: Release for Building Permits . SDP 99-687, USA Gasoline Station The Riverside County Fire Department hereby releases the above referenced project for issuance of a building permit at the discretion of the Building Department. . Re ctfully, Dale A. Bvenson Fire Safety Specialist BIERGENCY SERVICES DIVISION - PLANNING SECUON - INDIO OFFICE 82-675 Highway in, 2"d Fl., Indio, CA 92201 • (760) 863-80% - Fax (760) 863-7072 06-29-01 10:2S RECEIVED FR0M:1 760 863 7072 P.02 USA PALISADES GAS AND WASH CORPORATION sasnwne 30101 Agoura Court, Ste. 200, Agoura Hills, CA 91301-4311 Phone: (818) 865-9200 1 Fax (818) 865-0092 June 29, 20'01 City of LaQuinta 78-495 Calle Tampico LaQuinta,. CA 92253 RE: Letter of Authorization To Whom It May Concern: This letter serves as authorization for Ronald Riley, Construction Supervisor to serve as USA Corporate Representative for the purposes .of signing as Agent for Owner for our Site Development Permit, Conditional Use Permit, or any additional submissions.or applications related to this project. We additionally authorize Ronald Riley to pull any applicable permits for our project as Agent for Owner. Feel free to call me at 818-865-9200 if you have any questions or comments on this matter. Thank you for your assistance. Sincerely, VV1,� CLQKkip Michael M,,Googan ` ? P�. Notice: Document Cannot Be Duplicated Date 7/5/01 No. 22220 Desert Sands Unified School District 47-950 Dune Palms Road La Quinta, CA 92253 760-771-8515 CERTIFICATE OF COMPLIANCE APN # 649-020-051 Jurisdiction La Quinta owner NamePalisades Gas & Wash, Inc. No. 79-490 Street Highway 111 City La Quinta Zip 92253 Tract # Type of Development Comments 0017 Lot # Permit # Log # Study Area Square Footage 3360 Commercial No. of units 1 bldg. is gas station canopy - 3360 s.f. At the present time, the Desert Sands Unified School District does not collect fees .on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: Commercial Building EXEMPTION NOT APPLICABLE This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of .33 ' X 3,360 or $ 1,108.80 the property listed above and that building_, permits and/or Certificates of Occupancy for this square footage in this proposed project may now.be issued ., Fees Paid By CC / Union Bank of California -Ron Riley Telephone -818-865-9200 Name on the check xJ = By Dr. Doris Wilson - Superintendent ' Fee collected /exe pted by Annette Barlow Payment Received $1,108.80 Check No. 7484890 Signature 40TICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified ibove will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to ;ollect them on the District('s)(s') behalf, whichever is earlier. Collector: Attach a copy of county or city plan check application form to district copy for all waivers. Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting