07-1915 (RC)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
T4ht 4 4 Q"
Applicant: Architect or Engineer:
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.
License Class: B License No.: 7103�9/1
Dale: II Contractor: Y
OWNER -BUILDER DECLARATION u
I hereby affirm under penalty of perjury that m e ' pt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and Pro essions 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 05001.:
1 _ I I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and L
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 exclusivelycontractingwith 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
1 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:
LQPER114IT
Owner: .
WALMART STORES, INC.
2001 SE 10TH STREET'
BENTONVILLE
BENTONVILLE, AR.72716
Contractor:
CSI CONSTRUCTION CO
9272 JERONIMO ROAD,
IRVINE, CA 92618
(949)380-3900
Lic. No.: 710391
STE 4
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/21/07
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 CONT INS Policy Number 1098385252
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
700 of the abor de,
IAshall forthwith compl with those pr visi �
Date: /� O Applicant fes`
WARNING: FAILURE TO SECURE.W S' 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 authorize representatives
of this u ty enter upon the above-mentioned pro y for inspection purpo� 1
Date: I� () Signature (Applicant or Agent): /// Gw__
Application Number:
07-00001915
Property Address:
79315 HIGHWAY 111
APN:
649 -030 -034 -
Application description:
REMODEL - COMMERCIAL
Property Zoning:
REGIONAL COMMERCIAL
Application valuation:
10000
T4ht 4 4 Q"
Applicant: Architect or Engineer:
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.
License Class: B License No.: 7103�9/1
Dale: II Contractor: Y
OWNER -BUILDER DECLARATION u
I hereby affirm under penalty of perjury that m e ' pt from the Contractor's State License Law for the
following reason (Sec. 7031.5, Business and Pro essions 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 05001.:
1 _ I I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and L
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 exclusivelycontractingwith 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
1 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:
LQPER114IT
Owner: .
WALMART STORES, INC.
2001 SE 10TH STREET'
BENTONVILLE
BENTONVILLE, AR.72716
Contractor:
CSI CONSTRUCTION CO
9272 JERONIMO ROAD,
IRVINE, CA 92618
(949)380-3900
Lic. No.: 710391
STE 4
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 8/21/07
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 CONT INS Policy Number 1098385252
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
700 of the abor de,
IAshall forthwith compl with those pr visi �
Date: /� O Applicant fes`
WARNING: FAILURE TO SECURE.W S' 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 authorize representatives
of this u ty enter upon the above-mentioned pro y for inspection purpo� 1
Date: I� () Signature (Applicant or Agent): /// Gw__
Application Number . . . . . 07-00001915
Structure Information EXIST'G DEMO RM 912
Other struct info . .
. . . CODE EDITION
01BMP04EOSEN
FIRE SPRINKLERS
YES
MIXED-USE OCCUPANCY
NA
OCCUPANT LOAD
.00
1ST FLOOR SQUARE FOOTAGE
.00
----------------------------------------------------------------------------
2ND FLOOR SQUARE FOOTAGE
.00
Permit
BUILDING PERMIT
Additional desc
ELECT RANGE & TYPE 1 HOOD
Permit Fee
117.00 Plan Check Fee
76.05
Issue Date
Valuation . .
. 10000
Expiration Date '.
2/17/08
Qty Unit Charge
Per
Extension
BASE FEE
45-.00
8.0.0 9.0000
----------------------------------------
THOU BLDG 2,001-25,000
-----------------------------------
72.00
Permit . . .
ELECT - ADD/ALT/REM
Additional desc
ELECTRICAL FOR RANGE AND HOOD
Permit Fee
15.00 Plan Check Fee
3.75
Issue.Date . . .
Valuation
0
Expiration Date..
2/17/08
Qty Unit.Charge
Per
Extension
BASE FEE
6.75
3.00 .7500
PER ELEC DEVICE/FIXTURE 1ST 20
2.25
2.00 3.0000
-------------------------------------------=--------------------------------
EA ELEC APPLIANCES
6.00
Permit
MECHANICAL
r
Additional desc
RANGE HOOD
Permit Fee . . . .
. 21.50 Plan Check Fee
5.38
Issue Date
Valuation . .
. . 0
Expiration Date
2/17/08
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 6.5000
EA MECH EXHAUST HOOD
6.50
---------------------------------------------------------------
Special Notes and Comments
-------------
REVISION #6 -ADD ELECTRIC
RANGE AND TYPE
1 EXHAUST HOOD TO DEMO ROOM #912.
INCLUDES ELECT AND MECH.
PERMITS. CCD
#21.2001 CBC,CM.C,2004
CEC CODES.
LQPER11IIT
LQPE%11IT
Application Number
07-00001915
--------------------------------------------
Special Notes and
Comments
----------
-------------------
---
**DUCT WRAP SHALL
BE APPROVED
BY THE .
BUILDING OFFICIAL
PRIOR TO
INSTALLATION**
Fee summary
-----------------
Charged.
----------
Paid
----------
Credited
--------------------
Due
Permit Fee Total
153.'50
.00
.00
153.50
Plan Check Total
85.18
.00
.00
85.18
Grand Total
238.68
.00
.00
238.68
Bin,.#�
y
i
City of La Quinta
Building U Safety Division ,
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit .#
1�.
Project Address: --TGA _ 3 (� �1
Owner's Name:. wcdmclrS+VVCS
'A. P. Number:
Address: 2-001 S f 1 O +i i Si—
Legal Description:
City, ST, Zip:
Contractor: CS
Telephone:
Address:
Project Description: S a ryl , S
City, ST, Zip:
rl S ei1 e0-h-lC— M Yl 6 el Ot7
Telephone:
State Lic. # :
ILI
City Lic. #:
Arch., Engr., Designer.
Address:
City, ST, Zip:
Telephone:
State Lic. #:
Name of Contact Person:ff,?cnl aVF
Construction, Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Sq. Ft.:
#Stories:
#Units:
Telephone # of Contact Person: ' (� Zlo ► — &qv a X 1
Estimated Value of Project: 10 t 000
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING .
PERMIT FEES
zPlan
Sets
Plan Check submitte
Item
Amount
Structural Calcs.
Reviewed, ready f?f corrections O
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Cales.
Plans picked up
Construction
Flood plain plan.
Plans resubmitted
Mechanical
Grading. plan
2"' Review, ready for correctio a
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmittedGrading
.
M
IN HOUSE:
''" Review, ready for correction issu
Developer Impact Fee
Planning Approval
Called Contact Perso 0/2-
l yPub.
.Pub.Wks. Appr
Date of permit issue
School Fees
rl
AWG M140
P. 1
Total Permit Fees