BSPN2016-000178-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
c&,y °t 4 Qubtz
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Application Number: BSPN2016-0001
Property Address: 79785 HIGHWAY 111101
APN: 600440006-
Application,
00440006Application. Description: KOMAR / LIGHT HOUSE / NEW STORE INSPECTION
Property Zoning:
Application Valuation:
Applicant:
CAROLINE HALCOVICH
73605 DINAH SHORE DR 1403
PALM DESERT, CA 92211
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 Professions Code,
and my.License is in full force and effect.
License Class: License No.:
Date:
Contractor:
OWNER -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 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. 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. Q.
Lender's Name:
Lender's
33
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7.153
Date: 1/5/2016
Owner:
P6K PORTFOLIO KDP
2301 ROSECRANS STE 2110
EL SEGUNDO, CA 92253
Llc. No.:
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 polity number are:
Carrier: _ Polity Number: _
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 become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 Building Official 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 �qch permit, or cessation of
work for 180 days will subject permit to cancellation. / I
I certify that I have read this application and state th t the �tet
e information's correct.
I agree to comply with all city and county on dinanc s an slaws relai` to building
constructi n, an heceby authorize representativ oft o a uponthe
aboventleO r ertyfor inspection purpos s.
Date: c7 Signature (Applicant o e t):
Contractor:
m C3
m
M �
a G77
Llc. No.:
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 polity number are:
Carrier: _ Polity Number: _
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 become subject to the
workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith
comply with those provisions.
Date:
Applicant:
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION 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 Building Official 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 �qch permit, or cessation of
work for 180 days will subject permit to cancellation. / I
I certify that I have read this application and state th t the �tet
e information's correct.
I agree to comply with all city and county on dinanc s an slaws relai` to building
constructi n, an heceby authorize representativ oft o a uponthe
aboventleO r ertyfor inspection purpos s.
Date: c7 Signature (Applicant o e t):
FINANCIAL •• •
DESCRIPTION': : ; =ACCOUNT a QTY AMOUNT; :
PAID '
PAID DATE
SPECIAL INSPECTION 101-0000-42404 0 $72.52
$0.00
G PAID. BY '� • METHOD `RECEIPT #
CHECK #
CLTD BY
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $72.52 $0.00
TOTALS:00
Description: KOMAR / LIGHT HOUSE / NEW STORE INSPECTION
Type: SPECIAL INSPECTION
Subtype: Status: UNDER REVIEW
Applied: 1/5/2016 SKH
Approved:
Parcel No: 600440006 Site Address: 79785 HIGHWAY 111 101 LA QUINTA,CA 92253
Subdivision: PM 036269
Block: Lot: 6
Issued:
Lot Scl Ft: 0
Building Scl Ft: 0 Zoning:
Finaled:
Valuation: $0.00
Occupancy Type: Construction Type:
Expired:
No. Buildings: 0
No. Stories: 0 No. Unites: 0
Details: SPECIAL INSPECTION - NEW STORE OPENING. THIS PERMIT IS NOT FOR WORK. 2013 CALIFORNIA BUILDING CODES.
CHRONOLOGY
NAME TYPE
NAME
CONTACTS
ADDRESS1, CITY
STATE
ZIP
PHONE
FAX
EMAIL
APPLICANT
CAROLINE HALCOVICH
73605 DINAH SHORE PALM DESERT
DR 1403
CA
92211
OWNER
P6K PORTFOLIO KDP
2301 ROSECRANS STE EL SEGUNDO
2110 1
CA
92253
1
.
Printed: Tuesday, January 05, 2016 10:48:59 AM 1 of 2
SYSTEMS
ATTACHMENTS
Printed: Tuesday, January 05, 2016 10:48:59 AM 2 of 2
SYSTEMS
Bin #
City of La Quinta
Building & Safety Division
. . 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #
51Vroject Address: �, I l wner's Name:
A. P. Number: ( V Address:
Legal Description:—1 k t (-I-C�, City, ST, Zip:
act •
nr r. o
Co t Telephone:
Address: Project Description:
City, ST, Zip: �" 13*L)5iAv:---5S —
Telephone:
o
State Lie. # : City Lie. #:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Pan
n Type: e: Occupancy:
cYCon tTelePhone: ucti
State Lie. Pro•ecttYP (circleleo one): New Add'n Alter Repairair Demo
Name of Contact Person: L�k # Stories: # Units:
Telephone # of Contact Person: '51 C. Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rcc'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cafes.
Reviewed, ready for corrections
Plan Check Deposit
Truss Cafes.
Called Contact Person
Plan Check Balance.
Title 24 Cafes.
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
Plans resubmitted
Grading
IN ROUSE:-
'"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,'
Total Permit Fees