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BCOM2017-0018Applicant: ' BRITTANY LANCE 11 E. MADISON ST STE 300 CHICAGO, IL 60602 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code, and my License is in full force and effect. License Class: B License No.: 850746 Date � �S �� ' Contractor ICL S{� 1 ��,( t.) c � 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, 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 Na Lender's Contractor: RICK SHIPMAN CONSTRUCTION INC 15018 COUNTY ROAD 413 DEXTER, MO 63841 (573)624-5065 Llc. No.: 850746 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 hg Mor which this permit is issued. (/�—� have and will maintain workers' compensation insurance, as required by ecUon 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: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy Number: DTJUB4B86512A _ 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. Dater Is -b-7 Applicant: (C �r'1 17 MAN CCi��T. 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 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 enter upon th above-mentioned property for inspection purposes. 41141 Date:// ! Signature (Applicant or Agent): v VOICE (760) 777-7125 78-495 CALLE TAMPICO FAX(760) 777-7011 LA QUINTA, CALIFORNIA 92253FAX DESIGN &DEVELOPMENT DEPARTMENT (760) 777-7153 BUILDING PERMIT Date: 8/15/2017 Application Number: BCOM2017-0018, Owner: Property Address: 79295 HIGHWAY 111 WAL MART REAL ESTATE BUSINES APN: 600340027 P 0 BOX 8050 Application Description: WALMART / WALMART RE. BUS. TRUST / "GROCERY PICKUP" REMODEL BENTONVILLE, AR 92253 Property Zoning: . Application Valuation: $46,000.00 Applicant: ' BRITTANY LANCE 11 E. MADISON ST STE 300 CHICAGO, IL 60602 LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code, and my License is in full force and effect. License Class: B License No.: 850746 Date � �S �� ' Contractor ICL S{� 1 ��,( t.) c � 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, 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 Na Lender's Contractor: RICK SHIPMAN CONSTRUCTION INC 15018 COUNTY ROAD 413 DEXTER, MO 63841 (573)624-5065 Llc. No.: 850746 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 hg Mor which this permit is issued. (/�—� have and will maintain workers' compensation insurance, as required by ecUon 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: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA Policy Number: DTJUB4B86512A _ 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. Dater Is -b-7 Applicant: (C �r'1 17 MAN CCi��T. 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 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 enter upon th above-mentioned property for inspection purposes. 41141 Date:// ! Signature (Applicant or Agent): v a D Date: 8/15/2017 Application Number: BCOM2017-0018 Owner: Property Address: 79295 HIGHWAY 111 WAL MART REAL ESTATE BUSINES APN: 600340027 P 0 BOX 8050 Application Description: WALMART / WALMART RE. BUS. TRUST / "GROCERY PICKUP" REMODEL BENTONVILLE, AR 92253 Property Zoning: Application Valuation: $46,000.00 Applicant: Contractor: BRITTANY LANCE RICK SHIPMAN CONSTRUCTION INC 11 E. MADISON ST STE 300 15018 COUNTY ROAD 413 CHICAGO, IL 60602 _ DEXTER, MO 63841 (573)624-50.65 ---------------------------------------------------------------------------------------------- Llc. No.: 850746 Detail: 1,440 SQ.FT. FREESTANDING FABRIC CANOPY PER ENGINEERED DESIGN. REMODELED CASH REGISTER CHECKSTANDS FOR ONLINE GROCERY PICKUP FUNCTION, NEW REPLACEMENT EXIT DOOR WITH LIGHTING. 2016 CODES a D FINANCIAL •• a. DESCRIPTION ACCOUNT QTY AMOUNT HOURLY CHARGE - CITY BUILDING STAFF 101-0000-42600 2'.5 $380.00 DESCRIPTION ACCOUNT QTY AMOUNT HOURLY CHARGE - YES ADMINISTRATIVE STAFF 101-0000-42600. 0.25 $10.00 DESCRIPTION ACCOUNT QTY AMOUNT HOURLY CHARGE - YES STRUCTURAL PLAN REVIEW ENGINEER 101-0000-42600 2 $190.00 Total Paid for BLDG CITY STAFF - PER HOUR: $580.00 DESCRIPTION ACCOUNT QTY AMOUNT BSAS SB1473 FEE 101-0000-20306 . 0 $2.00 Total Paid for BUILDING STANDARDS ADMINISTRATION BSA: $2.00 DESCRIPTION ACCOUNT QTY AMOUNT DEVICES, FIRST. 20 101-0000-42403 0 $25.33 DESCRIPTION ACCOUNT QTY AMOUNT DEVICES, FIRST 20 PC 101-0000-42600 0 $25.33 Total Paid for ELECTRICAL: $50.66 DESCRIPTION ACCOUNT QTY AMOUNT NEW CONSTRUCTION PERMIT 101-0000-42400 0 $477.10 Total Paid for NEW CONSTRUCTION PERMIT: $477.10 DESCRIPTION ACCOUNT QTY AMOUNT NEW CONSTRUCTION PLAN CHECK 101-0000-42600 0 $857.22 Total Paid for NEW CONSTRUCTION PLAN CHECK: $857.22 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, EA ADDITIONAL 500 SF 101-0000-42400 0 $22.80 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, EA ADDITIONAL 500 SF PC 101-0000-42600 0 $18.24 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST 100 SF 101-0000-42400 0 $51.68 DESCRIPTION ACCOUNT QTY AMOUNT REMODEL, FIRST S00 SF PC 101-0000-42600 0 $141.36 Total Paid for REMODEL: $234.08 DESCRIPTION ACCOUNT QTY AMOUNT SMI - COMMERCIAL 101-0000-20308 0 $12.88 Total Paid for STRONG MOTION INSTRUMENTATION SMI: $12.88 DESCRIPTION ACCOUNT QTY AMOUNT TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 i Bin .# 018 City Of _U. Quthtd Building 8i' Safety Division P.O. Box 1504,78-495 Calle Tampico 14.Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking S�eet Permit # 3i3OM Utz= 0 Project Address:5 - ' Owner's Name:. A. P. Number. Address: Legal Description: City, ST, Zip: 2�-�� Contractor: Telephone q, 3• 0.r ;i;sx'v Address: Q +3 Project Description: 0nli f , , City, ST, Zip: Telephone:awo - 5 0 a , .>? State Lic. # : City Lic. #: Min Y_ Arch., Engr., Designer: ty JOIN Address:, awachea. City., ST, Zip: 1() iL mot Telephone: 1 Construction Type:. Occupancy: State Lic. #: ?� Ci 21)5 3 „•,, rr ' , ,N Project type (circle one): New Add'n Alter Name of Contact Person: l IPS , �� Sq. Ft.: 3D0 #Stories: Repair Demo #Units: Telephone # of Contact Person: Estimated Value of Project APPLICANT: DO NOT WRITE BELOW THIS LINE N Submittal Req'd Recd TRACMG PERMTI' FEES Plan Sets Pian Check submittedItem Amount Structural Cales. Reviewed, ready for corrections Plan Check Deposit. . Truss Cates. .'Called Contact Person Plan Check Balance Title 24 Cales. Plans picked up Construction Flood plain plan Pians resubmitted ' Mechanical Grading plan tad 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 HOUSE:- '^` Review; ready for correctionsfissue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Tota! Permit Fees