BSPN2019-002578-495 CALLE TAMPICO � D
LA QUINTA, CALIFORNIA 92253 DESIGN & DEVELOPMENT DEPARTMENT
BUILDING PERMIT
Permit Type/Subtype: SPECIAL INSPECTION/
Application Number: BSPN2019-0025
Property Address: 79261 HIGHWAY 111
APN: 600340022
Application Description: III) RELEASE / SPECIAL INSPECTION OF PEDESTAL
Property Zoning:
Application Valuation:
Applicant:
JUAN C OSPINA P
4001 W SEGERSTROM AVE DEC 12 2019
SANTA ANA, CA 92704
CITY OF LA QJlNTA
DESIGN & DEVELOPMENT DEPARTMENT
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.
Lice nseClass: Lice se No.:
1 o
Conti
OWNER-8 ILDER 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.).
(_) 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
Lender's Address:
VOICE (760) 777-7125
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 12/12/2019
Owner:
STAMKO DEV CO
3856 VIA DOLCE
MARINA DEL REY, CA 0
Contractor:
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
of the work for which this permit is issued.
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: _
j, 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 th7fle provi " ns.
Milo 12 /cM -�
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 ofthis 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 nter upon the above -
mentioned prop for spectivrtpurposes.
Ijg (Applicant or Agent). �� V
Date: 12/12/2019
Application Number: BSPN2019-0025
Property Address: 79261 HIGHWAY 111
APN: 600340022
Application Description: IID RELEASE / SPECIAL INSPECTION OF PEDESTAL
Property Zoning:
Application Valuation:
Applicant:
JUAN C OSPINA
4001 W SEGERSTROM AVE
SANTA ANA, CA 92704
Owner:
STAMKO DEV CO
3856 VIA DOLCE
MARINA DEL REY, CA 0
Contractor:
Llc. No.:
Detail: SPECIAL INSPECTION FOR PEDESTAL THAT POWERS MONUMENT SIGNS. PER 2016 BUILDING CODES. METER #4A5B-200585
Arch/Eng Name: Construction Type: Occupancy:
Address: Grading:
City, St, Zip
Telephone: Bedrooms: Stories: # Units:
Email:
State Lic: City Bus Lic:
78495 CALLE TAMPICO LA QUINTA, CA 92253 (760)777-7125
W W W. LAQU I NTACA.GOV
Z s �s� • r�osc��t�
OFFICE USE ONLY
# Submittal Req'd Rec'd
Plan Sets
Structural Calcs
Truss Calcs
Title 24 Calcs
Soils Report
Grading Plan (PM10)
Landscape Plan
Subcontractor List
Grant Deed
HOA Approval
School Fees
Burrtec Debris Plan
Planning approval
Public Works approval
Fire approval
City Business License
Form
'_9 Request for Taxpayer Give Form to the
(Rev. October2018) Identification Number and Certification requester. Do not
i]epenment of the Treasury send to the IRS.
tntemal Revenue Service ► Go to www.irs.gov/F`ortnWg for instructions and the latest information.
U
N
a
y
m
a)
1 Pvamv tds snuwn on your income tax return). Name is required on this line; do not leave this :me blank.
Valmart Inc.
2 Business nameldisregarded entity name, if different from above
DBA
Inc
3 Check appropriate box for federal tax classification of the person whose name is entered on line I. Check only one of the
following seven boxes.
❑ Individual/sole proprietor or ❑✓ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate
single -member LLC
❑ Limited liability company. Enter the tax classification (G_C corporation, S-S eorporaWn, P=Partnership) ■
Ndta: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
LLC if the LLC is classified as a singWmember LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that Is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC the
is disregarded from the owner should check the appropriate box far the tax classification of its owner.
Other (see instructions) Ili -
street, and apt. or suite no.) See instructions.
Tat SW 8Th Street
$ City, state, and ZIP trade
Bentonville, Arkansas, 72716
7 List account number(s) here (aptiom
eL Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
010O •s to accounts maintained outside the U.S.)
name and
Social security number
or
Illayer identification number
7 F1- 0 4 1 5 1 8 F8
Under penalties of perjury, I certify that:
1, The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2.1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b)1 have not been notified by the Internal Revenue
Service (IRS) that I ant subject to backup withholding as a result Of a failure to report all interest or dividends, or (c) the IRS has notified me that ( am
no longer subject to backup withholding; and
3. 1 am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) )ndicating that I am exempt from FATCA reporting is correct.
Certification Instructions. You must crass out Item 2 above ff you have been notified by tha IRS that you are currently subject to backup withho)dIng because
you have failed to report all Interest and dividends on your tax return. For real estate transactions, Item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other thart interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later.
Sign Signatureof
Here U.S. person■
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments, For the latest Information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to Www.1mgav1FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
Identification number (rlN) which may be your social security number
(SSN), individual taxpayer Identification number (MN), adoptlon
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are no( limited to, the fctlow)ng.
• Form 1099-INT (interest earned or paid)
Date ► Ll f
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
ffyou do not return Form W-9 to the requester with a 77N, you might
be subject to backup withholding, See What Is backup withholding,
later,
Cat. No. 10231X Form W-9 (Rev. 10-2018)
lID
COMMERCIAL APPLICATION
I1U-755 (R11 4-12)
SERVICE ORDERI COM APPLICATION
Lnca[ton
79-295 US Huey 111 La Quinta, California -
Mall Bill To
PO Box 967 Mandan, ND 58554
Pdncrpai Place of Business (Address)
79-295 US Hwy 111 La Quinta, CA 92253
7 of Business
ie ail
Is Business a Sole Propnelorship (if so, name)
Spouse's Namq r Address
IS Business a Partnership ilf so, names)
i,)
Walmart Inc.
V,rress As (DBk)-
rt #1805 - Sign
is Business a CorWat;on9 (It so, plane of Ineorpceation)
Delaware
Aresiden[
John Furner
Y. Allison
Print Name of 163 i'erson Siyrnng
Debra James
Title
Director Energy Strateqy
Driver's Licerise No -
Name of 2nd Person Signing
Title
Federal Tax Nce
71-0415188
Driver's LicenseNo
L�Etc"`f2f Mr3;flDreiai's�3n Anide5 of IncoTo.at:Qn
Phone ft (J [el
V
479-204-0097
Soc. $f. No.
71-0415188
j Staler
n
B M
Imperial Irrigation District
Regulations Goveminq Sale And Use of Electric Energy
EXcerpl*-from R$czL ggort_F
The customer shall, al his own risk and expense, furnish, instalt and keep in good and safe condition all electric wires. lines. machlnory
and apparatus of any son which may be required for receiving electric energy from the District. and for applying and utilizing such energy.
Including all necessary protective appliances and suilable housing therafW. The a(strlct shall not be responsible for any toss or damage
occasioned or caused by the negligence or want of proper care or wrongful act of the customer or any of his agents. employees or krAMSees
on the part of the customer in installing, maintaining, using, operating or inlevfenng wish any such wires, lines, machinery or apparatus,
Ex�Pfpts lrgrnggietion Np, 14
The District shall, at its option, have the right lo: disconnect its services until the customer has complied with all the terms of the agreement
and of the District's regulation.
EXCL91'Wra J9IILi39�llr li4fl hlo. f-
The District will construct, own, operate and maintain lines only along public streets, roads and highways which the District has the legal right to
occupy and on public lands and private property across which rights -of -way satisfactory to the Vistricl may be obtained +eilhout cast Of
condemnallon by the District,
!UI Imperitaf ftgalton District Regulations Governing Sale and Use of Electric Energy are available for viewing at all IID Division Offices and imperial Operating
Neadquaaters-
The undersigned applicant hereby certifies that he has read and understands the regulations governing the sale and use of electric energy primed above
and requests that Imperial Irrigation District supply electric service required at the address shown until such time as written or accepted telephone notice of
discontinuance is given, and In oonsideralion thereof does hereby agree to abide by the rules and regulations adopted by the Board of Directors of lmperiat
Irrigation District, and to pay all billsor services rendered pursuant thereto under the rates Adopted by said Board of Directors-
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