BSPN2016-001878-495 CALLE TAMP.ICO
LA QUINTA, CALIFORNIA 92253
T4tw44 Qu;.rw
COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING PERMIT
777-7125
FAX ) 777-7011
) 777-7153
FEB 12 201,s
Da 2/12/2016
Application Number: BSPN2016-0018 Owne co CRY OF LAQUINTP�'
Property Address: 79800 HIGHWAY 111 107 BEHR BLOPN!EAITDEPARTRlENT
APN: 600010021 363 N LA CIENEGA BLV
Application Description: MATTRESS SHOWROOM SPECIAL INSPECTION WEST HOLLYWOOD, CA 92253
Property Zoning:
Application Valuation:
Applicant: Contractor:
MATTRESS SHOWROOM INC
79800 HIGHWAY 111 STE 107
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 Professions Code,
and my License is in full force and effect.
License Class: License No.:
Date: I 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).:
( ) 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 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 reaspn
Date: %J1Cw7 10'/fW Owner
. CONSTRUCTION LENDING WGENCY.
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:
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
oftlle_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: _ Policy 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 come subject to the
workers' compensation provisions of Section 3700 of r Code, I shall forthwith
comply with tha pr isions.
Date: Applic t:
WARNING: FAILURE TO SECURE WORKERS' COMPEKNALTIES
COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P 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 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 city to ent n the
above -mention pr erty for inspection purposes.
Date: Signature (Applicant or Age
DESCRIPTION Y
FINANCIAL INFORMATION
ACCOUNT CITY AMOUNT
PAID
PAID DATE
SPECIAL INSPECTION
101-0000-42404 0 $72.52
$72.52
2/12/16
PAID BY
METHOD RECEIPT # ;• ,,.;
CHECK #'
CLTD BY
MATTRESS SHOWROOM INC
CHECK R12888
11052
MFA
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $72.52 $72.52
Description: MATTRESS SHOWROOM SPECIAL INSPECTION
DESCRIPTION ACCOUNT QTY AMOUNT
Type: SPECIAL INSPECTION
Subtype:
Status: ISSUED
Applied: 2/12/2016 MFA
Approved: 2/12/2016 MFA
Parcel No: 600010021 Site Address: 79800 HIGHWAY 111107 LA QUINTA,CA 92253
Subdivision: PM 34123
Block: Lot: 1
NAME
Issued: 2/12/2016 MFA
Lot Sq Ft: 0
Building Sq Ft: 0
Zoning:
Finaled:
Valuation: $0.00
Occupancy Type:
Construction Type:
Expired: 8/10/2016 MFA
No. Buildings: 0
No. Stories: 0
No. Unites: 0
92253
Details: SPECIAL INSPECTION FOR BUSINESS LICENSE APPROVAL
Appnea m Approvea
ice: Approved to Issued
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT QTY AMOUNT
CONTACTS
PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD
BY
SPECIAL INSPECTION 101-0000-42404 0 $72.52
NAME TYPE
NAME
ADDRESSI
CITY
STATE
ZIP
PHONE
FAX
EMAIL
APPLICANT
MATTRESS SHOWROOM INC
79800 HIGHWAY 111
STE 107
LA QUINTA
CA
92253
OWNER
BEHRSTOCK PROP
363 N LA CIENEGA BLV
WEST
HOLLYWOOD
CA
92253
FINANCIAL INFORMATION
DESCRIPTION ACCOUNT QTY AMOUNT
PAID
PAID DATE RECEIPT # CHECK # METHOD PAID BY CLTD
BY
SPECIAL INSPECTION 101-0000-42404 0 $72.52
$72.52
2/12/16 R12888 11052 CHECK MATTRESS MFA
SHOWROOM -INC
Total Paid for COMPLIANCE SURVEY/SPECIAL INSPECTION: $72.52 $72.52
Printed: Friday, February 12, 2016 2:05:10 PM 1 of 2 7
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Printed: Friday, February 12, 2016 2:05:10 PM 2 of 2 CR
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Birt #
Qty of La QCII[ to
Building &r Safety Division
78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and. Sheet
Permit #f
Project Address: ��
(�Y I ('j'� it
yTracking
t wner's Name: IMr to f; �GF_35
(pc_
A. P. Number:(
Address:
Legal Description:
City, ST, Zip:Q
Contractor.
e.(oi 0
Telephone:hon Oq -I 3
Address:
Project D scription:
City, ST, Zip:
e•
Telephone:
P 0
State Lie. # :
City Lie. #.:
Arch., Engr., Designer:
Address:
City, ST, Zip:
Telephone:
:
n TY Pe: Occupancy:c
Construction
ie. #:
ait
Project (circle one): w Add'n Alter 'Repair
De
moState
Namd,of Contact Person:
C(/%'�� O1�- ��
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: -7W
Estimated Value of Pro' ct:
APPLICANT: DO NOT WRITE BELOW THIS LINE
ti
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Cales.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance.
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan.
2ad Review, ready for-corrections/issue
Electrical
Subeontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN I10USE:-
Reyiew, ready for corrections/issue
Developer Iinpact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees,
Total Permit Fees