07-2265 (BLCK)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number:
07-00002265
Property Address:
79815 HIGHWAY 111
APN:
600 -020 -034 -
Application description:
WALL/FENCE
Property Zoning:
COMMERCIAL PARK
Application valuation:
11063
Applicant: Architect or Engineer:
LICENSED CONTRACTOR'S DECLARATION
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
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.
License Class, 13 C9 LicenseNo.:
436418
Date:2/ )) Contractor: IU._A �rO'07i
7 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 thealleged 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.)
(_ 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 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
Owner:
KOMAR INV
23 CORPORATE PLZ STE 247
NEWPORT BEACH, CA 92660
Contractor:
BERGMAN COMPANIES, THE
4300 EDISON AVENUE
CHINO, CA 91710
(909)627-3651
LiC. No.: 436418
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/17/07
AUG 2 () 2007
Glw by - 11 URNTA
FM 'G..:, µ
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:
Carrier AMERICAN INTL 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' compensation laws of California,
and agree that, if I should become subject to the workers' compensation provisions of Section
3700 of the Labor
/C�t¢ hall forthwith com I ith those provisions.
Date-7APPlicant: �L�TT �� I
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 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 uthorize representatives
of thisGcou_n�y to enter upon the above-mentioned prop for i pection purposes.
D��7�P9ature. (Applicant or Agentl:
Application Number 07-00002265
Permit . . . WALL/FENCE PERMIT
Additional desc RETAINING / SCREEN.WALLS
Permit Fee 135.00 Plan Check
Fee ..
.00
Issue Date . . . . Valuation
. . .
. 11063
Expiration Date . . 2/12/08
Qty Unit Charge Per
Extension
BASE FEE
45.00
10.00 9.0000 THOU BLDG 2,001-'25,000
90.00
----------------------------------------------------------------------------
Special Notes and Comments
387 L.F. 4' BLOCK WALL, 150 L.F. COMBO
WALL 4'' RETAINING, 1 1/4' GARDEN, AND
-
75 L.F. 5 1/4'*GARDEN WALL, ALL PER
APPROVED ENGINEERED SPECS.
TOP OF WALL ELEVATION REVISED TO 62.00'
@ NORTHEAST CORNER OF SITE. REFER TO
8.5 X 11 EXHIBIT W/ ENGINEER'S SEAL.
August 17, 2007 11:29:59 AM bhanada
Fee summary Charged Paid Credited
Due
Permit Fee Total 135.00 .00
.00.
135.00
Plan Check Total .00 .00
.00
.00
Grand Total 135.00 .00
.00
135.00
LQPER,NIIT
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