12-1354 (SOTB)P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
c&t . !t 4 4Q"
BUILDING & SAFETY DEPARTMENT
BUILDING PERMIT
Application Number: 12-00001354
Property Address: 79795 HIGHWAY 111
APN: 600-020-033- -
Application description: STRUCTURES OTHER THAN BUILDINGS
Property Zoning: COMMERCIAL PARK
Application valuation: 135000
Applicant:
I hereby affirm under penalty of pe
Section 7000) of Division 3 of the
License Wass: ,A
Architect or Engineer:
rRACTOR'S DECLARATION
under provisions of Chapter 9 (commencing with
lals Code, and my License is in full force and effect.
License No.: 888712
][ Date:.__.�}�-,�, Contractor: {/�/' ./\
• \ �� OWNER -BUILDER DECLARATION
I hefaby offlrm under penalty of perjury that I am exempt from the Contractor's State License Law for the
following reason (Sec. 7D31.5, Business and Professions Code: Any city cr county that requires a permit to
wrmcupt, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for the
permit to file a signed ststement ttint )te or she Is licanred pursuant to the provisions of the Cornfactor's State
License Law lCitapter 9 leornmencing with Saollan 70001 OF Division 3 of the Business and Professions Code) or
that he or site Jr. exempt therefrom and ilia basis for the alleged exemption. Any violation of Section 7031.5 by
any applicant Ior a pemilt subjects the applicant to a civil penalty of not more than five hundred dollars ($500).:
1 ! I, as owner of tlto propefty. Or my empleyoas with wages as their Sala compertaatlort, will do the work, and
tita 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 _ 1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
7044, Busltxres 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:
COSTCO WHOLESALE CORP
999 LAKE DRIVE
ISSAQUAH, WA 98027
Contractor:
W S K & SONS INC
34455 SUNLIGHT DR
YUCAIPA, CA 92399
(951)906-3023
Lic. No.: 888712
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 3/29/13
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' comps tip In ce, as required by Section 3700 of the Labor
Code, for the performance of the wor for It Y�lt Is permit Is issued. My workers' compensation
insurance carrier and policy number a :
Carrier NORGUARD INS CO Pau Nu b WSWC318899
I certify that, in the perform "' of the ark fo w loh this permit is issued, I shall not employ any
person in any manner so to e s j L a the workers' compensation laws of California,
and agree that, if I shout bowr a bj . t t a workers' compensation provisions of Section
3700 of the Labor Cod I hat for th ply with those provisions.
�IfNG
Applicant:
WARFAILURE TO SECURE WORKERS' CO PE14SATION 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 d hold harmless the City
of La Quints, its officers, agents and employees for any act or fission 1od to the work being
performed under or following issuance of this permit. 11
2. Any permit issued as a result of this application becomes nut n voi I )grork is not commenced
within 180 days from date of issuance of such permit, or s so tion f work for 180 days will subject
permit to cancellation.
I certify that I have read this application and state that the a eve infor U is or t. I agree to comply with all
city and county ordinartoas and state lairs relating to buildl cone)truc vn a i eby authorize representatives
of t111s County to,ontor upon t" above-mantloned property or fine ctt n urp
pats: Signature (Applicant or Agent): L
Application Number . . . . . 12-00001354
Permit .. . . BUILDING PERMIT
Additional desc .
Permit Fee 762.00 Plan Check Fee 495.30
Issue Date Valuation 135000
Expiration Date 9/25/13
Qty Unit Charge Per Extension
BASE FEE 639.50
35.00 3.5000 THOU BLDG 100,001-500,000 122.50
----------------------------------------------------------------------------
Permit . . .
Additional desc . .
Permit Fee . . . .
Issue Date . . . .
Expiration Date . .
ELEC-MISCELLANEOUS
27.50 Plan Check Fee . . 6.88
Valuation . . . . 0
9/25/13
Qty Unit Charge Per
Extension
BASE FEE
15.00
2.00 .7500 PER ELEC DEVICE/FIXTURE
1ST 20
1.50
1.00 11.0000 EA ELEC MISC
11.00
^^ Special Notes and Comments
1500 GALLON UNDERGROUND FUEL ADDITIVE
TANK PER ENGINEERED PLANS. INCLUDES
PIPING, CONDUITS AND ASSOCIATED
ELECTRICAL INSTALLATION. ENGINEER: HAL
P. GRUBB C 67814
-
-----------------:-:------------___�----------_------------
Other Fees . . . . . . . BLDG STDS ADMIN
(SB1473)
6.00
Fee summary Charged Paid Credited
'~
Due
Permit Fee Total 789.50 .00
.00
789.50
Plan Check Total 502.18 .00
.00
502.18
Other Fee Total 6.00 .00
.00
6.00
Grand Total 1297.68 .00
.00
1297.68
LQPERMIT