10-0125 (SPIN)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: , - % 10-00000i25'__
Property Address: 78130 CALLE ,TAMPICO
APN: 770-020-012- -
Application description: SPECIAL INSPECTION
Property Zoning: VILLAGE COMMERCIAL
Application valuation: 100
Applicant: Architect or Engineer:
�I
4
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
• 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 Professionals Code, and my License is in full force and effect.
Licensee Class: B C9 Li c 436418
_,--Date: r �p ontractor:
0 ER -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 ($500).:
1 _ 1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and
the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
and who does the work himself or herself through his or her own employees, provided that the
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving that he or she did not build or
improve for the purpose of sale.).
1 9 I, as owner of the property, am exclusively. contracting with licensed contractors to construct the project (Sec.
.' 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of
property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed
pursuant -to the Contractors' State License Law.). -
(_) I am exempt under Sec. , B.&P.C. for this reason
Date: Owner:
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the
work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name:
Lender's Address:
LQPERMIT
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 77777153"
Date: 2/19/10
Owner:
HIGHLAND LA QUINTA I LC
80 S LAKE AVE STE 6 /J Q
PASADENA, CA 91101
r
9 2613
Contractor: e'l$��-.
i
BERGMAN COMPANIES, �4.?;•.; `�<{s:;
4300 EDISON AVENUE `"-'t r.i
CHINO, CA 91710
(90.9)627-3651
Lib. No.: 436418
------------------
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 Cade, 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 LIBERTY INS. Policy Number WC5312540
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' co ensation laws of California,
and agree that, if I should become subject to the workers' com a ation provisions of Section
3700 of the Labor Code, 1 shall forthwith comply with thos visions.
ate: 2 "lei' (Dicam:
`WARNING: FAIL RE TO SECURE WORKERS' COMPENSATIO OVERAGE IS UNLAWFUL, AND SHALL C
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 information is correct. I agree to comply with all
city and county ordinances and state laws relating to building construction,. and hereby authorize representatives -
of this' ounty to enter upon the above-mentioned property for inspection purposes.
ate: Sigure (Applicaylt.er Agent):
Application Number 10-00000125
Permit . . . SPECIAL INSPECTION
Additional desc .
Permit Fee . . . . 100.00 Plan Check
Fee
.00
Issue Date . . . . Valuation
. . .
. 100
Expiration Date .8/18/10
Qty Unit Charge Per
Extension
BASE FEE
100.00
---------------------------
Special Notes and Comments
SPECIAL INSPECTION TO COMPLETE
CONSTRUCTION AND FINAL OFF "FRESH & EASY
MARKET". ORIGINAL PERMIT # './,
Oq _95
Fee summary Charged Paid Credited
Due
Permit.Fee Total 100.00 .00
.-00
100.00
Plan Check Total .00 .00
.00
.00
Grand Total 100.00 .00
.00
100.00
l "
� r2eeenniT ,
Bin #
City of La Quinta
Bw7dhlg & Safety DlvWM
Permit #
P.O. Box 1504, 78-495 Carte Tampko
" ,
La Quanta, CA 92253 - (760) 777-7012
�0
Building Permit Application and Tracking Sheet ,
Project Address:
Owner's Name: t
A. P. Number:
Address: 2t±444e-4) _
Legal Description:
City, ST, Zip: t,4 {meq c/4 -
Contractor:
Telephone:
Address:
Project Description:
City, ST, Zip:
hus 1)6
Telephone:
City Lic. C
Coa�S �1%7�"/vRJ
'
State Lic. # :
Arch., Engr., Designer.
Address:
City, ST, Zip:
Telephone: Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contac Person: Sq. Ft.: # Stories: # Units:
Telephone # of Contact Person: Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
# Submittal Req'd Rec'd TRACKING PERMIT FEES
Plan Sets Plan Cheek submitted Item Amount
Structural Cala
Reviewed, ready for corrections Plan Check Deposit
TYuss Cala.
Called Contact Person Plan Check Balance
Title 24 Cala.
Plans picked ap Construction
Flood plain plan
Plans resubmitted Mechanical
Grading plan
2'' Review, ready for corrections/inue Electrical
Subeontaetor List
Called Contact Person Plumbing
Grant Deed
Plans picked up S.M.I.
H.O.A. Approval
Plans resubmitted Grading
IN HOUSE:-
Review, ready for eorrectionstissuc Developer Impact Fee
Planning Approval
Called Contact Person A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees