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BCOM2016-004478-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT BUILDING PERMIT Jf Application Number: BCOM20.16-0044 Property Address: 78110 CALLE TAMPICO APN: 770020005 SEP 3 ® 2016 Application Description: CIRCLE K STORE / TI REMODEL Property Zoning: C!TYOFLAQl1!NTA . Application Valuation: $15,000:00 COMMUNITYDEVELOPP.fENTDEPARTMENT Applicant: ISLAND PETROLEUM BULDERS INC 0 OUTSIDE CITY LIMITS LA QUINTA, CA 92253 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 rofessions Code, and my License is in full force and effect. License Class: B. CSO, D400 License No.: 77 46 D V Contra VOICE (760) 777-7125 FAX (760) 777-7011 INSPECTIONS (760) 777-7153 Date: 9/30/2016 Owner: MARILYN FINE P 0 BOX 52085.DC17 PHOENIX, AZ 92253 Contractor- ISLAND ontractorISLAND PETROLEUM BUILDERS INC .7470 SVL BOX VICTORVILLE, CA 92392 (909)923-9373 LIC. No.: 776846 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: OWNLR-BUILDER DECLARATION Carrier: INSURANCE COMPANY OF THE WEST Polity Number: WSD5020021 I hereby affirm under penalty of perjury that I am exempt from the C ntractor's State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any I certify that in the performance of the work for which this permit is issued, I city or county that requires a permit to construct, alter, improve, demolish, or repair shall not employ any person in any manner so as to become subject to the workers' any structure, prior to its issuance, also requires the applicant for the permit to file a compensation laws of California, and agree that, if I should become subject to the signed statement that he or she is licensed pursuant to the provisions of the workers' compensation provisions of Section 3700 o the Labor Cod , shall forthwith Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division comply with those provisions: 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 fora Date: Applican permit subjects the applicant to a civil penalty of not more than five hundred dollars �� . ($500).: WARNING: FAILURE TO SECURE WORKE S' COMPENSATION COVERAGE UNLAWFUL, (_) I, as owner of the property, or my employees with wages as their sole AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVI FINES UP TO compensation, will do the work, and the structure is not intended or offered for sale. ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF (Sec. 7044, Business and Professions Code: The Contractors' State License Law does net COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, apply to an owner of property who builds or improves thereon, and who does the work INTEREST, AND ATTORNEY'S FEES. ; 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 APPLICANT ACKNOWLEDGEMENT within one year of completion, the owner -builder will have the burden of proving that IMPORTANT: Application is hereby made to the Building Official for a permit subject to he or she did not build or improve for the purpose of sale.). the conditions and restrictions set forth on this application. (_) I, as owner of the property, am exclusively contracting with licensed contractors 1. Each person upon whose behalf this application is made, each person at whose to construct the project. {Sec. 7044, Business and Professions Code: The Contractors' request and for whose benefit work is performed under or pursuant to any permit State License Law does not apply to an owner of property who builds or improves issued as a result of this application , the owner, and the applicant, each agrees to, and thereon, and who contracts for the projects with a contractor(s) licensed pursuant to shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and] the Contractors' State License Law.). employees for any actor omission related to the work being performed under,or (_)1 am exempt under Sec. B.&P:C.'for this reason 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 Date:- Owner: work for 180 days will subject permit to cancellation. 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: 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 building construction, and hereby authorize representativ above-mentioned property for inspection purpos Date: �0 nature (Applicant or Date: 9/30/2016 • Application Number: BCOM2016-0044 Owner: Property Address: 78110 CALLE TAMPICO MARILYN FINE APN: 770020005 P O BOX 52085 DC17 Application Description: CIRCLE K STORE / TI REMODEL PHOENIX, AZ 92253 Property Zoning: :I Application Valuation: $15,000.00 Applicant:' Contractor: ISLAND PETROLEUM BULDERS INC ISLAND PETROLEUM BUILDERS INC 0 OUTSIDE CITY LIMITS 7470 SVL BOX LA QUINTA, CA 92253 VICTORVILLE, CA 92392 - (909)923-9373 Llc. No.: 776846 Detail: INSTALL NEW COFFEE COUNTER WITH NEW FLOOR SINK. PER 2013 CBC'S CODES FINANCIAL •• • „ . .. DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-000,0-20306 0 $1.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $1.00 DESCRIPTION ACCOUNT QTY , AMOUNT WATER SYSTEM INST/ALT/REP 101-0000-42401 0 $12.09 DESCRIPTION ACCOUNT QTY AMOUNT WATER SYSTEM INST/ALT/REP PC 101-0000-42600 0 $12.09 Total Paid for PLUMBING FEES: $24.18 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST 100 SF 101-0000-42400 0 $49.31 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST 500 SF PC i 101-0000-42600 0 $134.88 ' Total Paid for REMODEL: • $184.19 TOTALS: t Bid if ty'. of Lat I�Gi ` � .Quin Buifding &r Safety Division rPennit u 4 78-495.Calle Tampico' ' LiQuinta, CA 92253 - (760) 777-701,2 16 co!t ZQ� -- ('�f Building, Permit Application and Tracking Sheet 'Project Address: _ CA Owner's Name: G r A. P. Number: . Address: Legal Description: , ' City, ST, Zip: p g (Contractor: Telephone: ( Address: * ( Project Description: , lAgS -7", 1 'City, ST, Zip: ---•- UlC.J-O TeP le�h ne• 0 O _ �t State Lic. # : ity, Al Arch., Engr., Designer: r Address:. City, ST, Zip: r a Telephone: Construction Type: O ccuP an cY• . State Lic . # ,. t • r ,. Project type (circle one), New Add'n ]ter Repair -air -Dcmo o Name of Contact Person:: U y Sq. FL: #Stories: # Units: �- Telephone # of Contact Person: `Estimated Value of Project: APPLICANT: DO NOT WRITE BELOW THIS LINE = H. Submittal Req'd Rcc'd TRACKMG PERMIT FEES Plan Sets . - Plan Check submitted • _ i ' Item Amount Structural Calcs. Reviewed, ready for correetions Plan Che_ckk TiUSS Cates. , Called Contact Person PI!a0iet Balance. Title 24 Calcs. Plans picked up ,,00 loC�oVnstruction Flood plain plan Plans resubmitted"•• '114echanical. t_ Grading plan 2"a Review, ready for correcli nsiisue Electrical Subcontactor List Called Contact Pcr - Plumbing Grant Deed Plans pi�k�cd>. S.M.L. II.O.A. Approval �g. al" n's resubmitted Grading ' IN IIOUSE:- '"' Review, ready for corrections/issue Developer Impact Fee Planning Approval /.,. Called Contact Person A.I.P.P., Pub. Wks: AApp�pr , Date of permit issue School es'. 'k l� y Total Permit Fees r . E � �kRETURNED� Y � � €i, .. � k,�`� ?f� JUIT DATE DUE,DATE TkYPE01k CONTA��. Review Grou AUTO.