7046PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
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Tract No: Project Name:-S"ouYN A,-i%4(hf tots
Vicinity:
Purpose of Construction (i.e.: Rough Grading, site Street tc.) SO (L- :�7NVtS I -
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Description. of Construction (i.e.: See Plan Set No. 01234) so ZtJV&YTt TIa/j
Dimension of Installation or Removal: f,fik
Approximate Construction Start Date:. 2- - Zg - 0
Approximate Construction Completion Date: - % —0
Estimated. Construction Cost: $ K !�
Estimated Construction Cost shall include the removal of all obstructions, materia and debris, back -filling; compaction and.
placing permanent resurfacing and or replacing improvements
Contact Name:
Name of Applicant/Owner: t-of 4CFN
Applicant Address: tq - µ3 W V Oe4A;r
Applicant Telephone Number: c - 3 2
Applicant E-mail Address: jtM �F
Name of Contractor:
Contractor Address:
Contractor Telephone Ni
Contractor State License
Contractor City Business
Contractor E-mail Addre
OZ)
Phone Number: UL4- = I SI -236 - 33 Z
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ember:. CS-7-7 010 i j
tense Number:
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ANT INSURANCE CERTIFICATE MUST BE PROVIDED -4
ant or Contractor Ge eral Liability
Applicant or Contractor
Office Use Only:
Inspection Fee: '
Permit Fee: 7
As -Built
Deposit: %
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE:
Company:
Insurance Policy Number:
Office Use Only:
Assigned Permit Number. qto
Approval Date: j
Expiration
Date:
Issue
Date:
Administrative Authority:
FOR PERMfr.doc
LGEOTECHNICAL GROUP, INC.
l R Soil Engineering • Geology • Environmental
Robert M. Markoff, PG, CEG
Engineering Geologist
6121 Quail Valley Court 19-438 Ruppert Street
Riverside, CA 92507 Palm Springs, CA 92262
(951)653-1760 (760)329-2727
Fax (951) 653-1741 Fax (760) 329-2626
Toll Free 8888 LORGEO Mail To: P.O. Box 580799
Email: rmarkoff@lorgeo.com N. Palm Springs, CA 92258
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Finance Department
(760)777-7000
FAX (760)777-7106
WORKER'S COMPENSATION DECLARATION
IF YOUR BUSINESS IS BEING OPERATED FROM A PRIVATE RESIDENCE WITHIN LA QUINTA, A HOME
OCCUPATION PERMIT IS REQUIRED BEFOREA BUSINESS LICENSE CAN SE ISSUED.
Every ernployer who applies for a Business License or License renewal which is to be issued pursuant -to Section
37101 of the Government Code or'Section '7284. of the Revenue and Taxation Code SHALL COMPLETE AN SIGN A DE LARATION THAT STATES ONE OF E. FOLLOWI G�
I HEREBY AFFIRM, UNDER PENALTY OR PERJURY, ONE OF THE FOLLOWING DECLARATIONS:
(Check One)
I Have and will maintain a Certificate of Consent to Self4nsure for Worker's Compensation,• as
provided by Section 3700-for the duration of a6y business`conducted for which a Business
/ License Is Issued.
L I Have and will maintain Worker's Compensation Insurance, as required b Section 37
the duration of any business conducted for which a Business Licee LS issued. 00 for
WORKER'S COMPENSATION INSURANCE CARRIER:
POLICY NUMBER:. W.ZQRDq�O�O EXPIRATION DATE: l i iJ&
(IF YOU DO NOT HAVE ANY EMPLOYEES, PLEASE INITIAL.I3ELOW)
I Certify that in the performance of any. Business activity for which -a Business License is
Issued, I shall not employ any person In any manner so as to become subject to the Worker's
Compensation Laws of the state of California, and l agree that if P should become subject to
the Workers Compensatlon provisions of Section 3700, 1 WIN provide the City with a Policy or
Certiigcate within ten (10) days of the change In requi►wnents.
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Applicant:
Date:
WARNING: FAILURE. TO SECURE WORKER'S COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL
.SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000. IN ADDITION TO
FINES AND PENALTIES, ADDITIONAL COMPENSATION DAMAGES, INTEREST -AND ATTORNEY'S FEES MAY
BE ASSESSED TO YOU AS PROVIDED IN. SECTION 3706 OF THE LABOR CODE. -
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Finance -Department
FAX • (760)777-7105
ATTENTION
UPON SUN=, AL -OF BUSINESS LICENSE RENEWALS, PLEASE SUBMIT
CURRENT COPIES OF THE FOLLOOWING:
_T R.MERSIAE COUNTY DEPARTMENT OF.HEALTH PERMIT .
County Environmental Health Services
2500 N. Palm Canyop, Ste: A3,.Palm Springs, CA
(760)320=1048 `
STATE OF CALIFOIR.NIA DEPARTMENT OF ALCOHLIC.BEVERAGE .
Alcoholic Beverage Coutrol
42700• Bob Hope Dr. Suite 317, Rancho Mirage? CA 927-76. .
(760)56&0990'
FICTITIo,Us BusnvESs NAME PFEB
RiversideCounty Clef k's Office 2 8
.82675 Hwy 111, Room i13, LuUo, CA 92Z01 2007
(760)863-7490 By
: RESALE ;I�UMBER/SELLER'S. PER
California Board of Equalization
427.00 B4 Hope Drive, Suite 3019 Rancho Mirage,• CA 92270
(760)34 096
HOME• OCCUPATION PERMITS
City of La Qaint'a, Code tnforcement .
78495 Cabe Tampico
La Quiuta, CA 92253.
.(760)777-7054
CERTIFICATE ON WORKERS COMPENSATION NSURANCE
IF COPIES OF THE MARKED rf MS ARE NOT RECEMD THIS MAY CAUSE A
DELAY IN TJJE PROCESSING OF YOUR BUSINESS LICENSE RENEWAL AND/OR
ADDITIONAL CHARGES. MAY .BX INCURRED.
IF YOU HAVE ANY QUESTIONS, r # ,,
-DEPARTMENT'AT (760)777-7000 ' post-itO° Fax Note 7671 Date
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Co. I�
--�` Phone #
Phone #
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Business License No.
OUT OF CITY BUSINESS LICENSE APPLICATION FORM (VEHICLE)
'FOR B=KiSPS NOT LOCATED NSIDE THE C" OPLA QUINTAM4S UGME DOES NOT APPLY TO BUILDING CONTRACTORS)
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BUSINESS LICENSE APPROVAL. APPROVED BY QgTE
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PROOF OF WORKERS COMPENSATION INSURANCE 19 REQUIRED PRIOR TO I�SUANCE IF APPLICABLE
1. ' . Business Name: We "fj C (1' I
2, Business Address; UQI �;� ( `.!� _tri � I u o I l e� Ct�u r �- Z i U-c I V d Q City/State• C Zip Code: j�-SU %
3. Mailing Address: SQ1'YN? City/State: Zip Code:
4, Business Phone: q51)
5. Owned by: Corporation: Partnership: Individual:
6. If Corporation or Partnership, Federal Tax I.D. is required: . .33 + 0 3119 X 951
ffi 7. Name of Owner or Officers and Tlae: ohn P Ug r, Pres, r P n4- y r
S. Type of Buslr ess
9. IF YOU.ARE A FOOD VENDOR, DO YOU HAVE A COUNTY HEALTH PERMfr:
0 YES (if yes, please provide a current copy) Q NO
10, La CNinra Resale Number (SEER sale number):
11. EVERY BUSINESS NOT HAVING A FIXED BUSINESS LOCATION WITHIN THE CITY OF LA QUINTA WHO DELIVERS TO LA
•QUINTA ANY SERVICES BY THE USE OF VEHICLES SHALL PAY A LICENSE FEE AS FOLLOWS: '
Capacity Rate per Vehicle Number of Vehicles
Less than.%Ton $15.00
% Ton to 2 Ton $25.00 t
Over 2 Ton to 3 Ton $50.00
Over 3 Ton $75.00
TOTAL LICENSE FEE DUE:
Please indicate below all vehicle license plate numbers that will be used in the business:
Vehicle License Plate Number Vehicle Make/Model
Permit Number'(Finance Use Only)
I HEREBY CERTIFY that all Information supplied by me Is correct and any licenses required by the County, State or Federal
Government have been Issued to me and are in full force and effect .
Signature: k Title: 1L ' ,r/ Date: 0- 7
Send Completed Form(s) to: CITY OF LA QUINTA
BUSINESS LICENSE DIVISON
P.O, BOX 1504
La Qulnta, CA 92247-1604
(760)7TT-7000
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