BLCK (04-5161)55215 Medallist Dr
04-5161
Taf ' -*
°F 4 Q"
P.O. BOX 1504
r=:7+8-495 CALLE TAMPICO
g`; -lin QUINTA, CALIFORNIA 92253
Tiber
Property Address.
APN:
Application description
Property Zoning . . .
Application valuation
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION' REQUESTS (760) 777-7153
BUILDING PERMIT
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0-5161 Date 6/25/04
. 55215 MEDALLIST DR
767-510-001-
.
67-510-001 . . . WALL/FENCE
LOW DENSITY RESIDENTIAL
. . . 3640
Owner. Contractor
NORMAN ESTATES II EHLINE COMPANY
C/O MEDALLIST GOLF DEVELOPMENT 55375 MEDALLIST DR
501 NORTH AlA LA QUINTA CA 92253
JUPITER FL 3.34.77 (760) 771-8130
WCC: STATE FUND
WC: 2290006783 01/01/05
CSLB: 482086 11/30/05
CCC: B
--------------------------------------7-------------------=-----------------
Permit . . . . WALL/FENCE PERMIT
Additional desc
Permit Fee 63.00 Plan Check•Fee .00
Issue Date . . . Valuation 3640
Qty Unit Charge Per Extension
BASE FEE `' 4"5.0 0
2.00 9.0000 THOU BLDG 2,001-25,000 18.00
--------
Special Notes and Comments
40 L.F. 3' BLOCK WALL, 120 L.F. 6' BLOCK
WALL, BOTH ORCO SYSTEM
Fee summary Charged Paid CreditedDue
Permit Fee Total 63.00 .00 .00 63.00
Plan Check Total .00 .00 .00 .00
Grand Total. 63.00 .00 00•: 63.00
--- P.O. BOX 1504
78-495 CALLS TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Addres
Architect or Engineer:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: (0 • .2 IR -04/
Hrcrinect or tnglneer's Address:
Lic. No..
BUILDING PERMIT DECLARATIONS
I hereby affirm under penaltyof
LICENSED CONTRACTOR'S DECLARATION
Perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
e, and my LicensVc in full force and effect.
icense Class C5 ✓ License No.—:7-0 Z
Date oZ O eontractor
I hereby affirm under penaltyof OWNER -BUILDER DECLARATION
perjury that I am exempt from the Contractors' 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 Contractors' 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 or a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as their sole compensation, wili do the work, and the structure is not intended or offered or 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 or 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 or the purpose of sale.).
U 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.).
U I am exempt under Sec. , BA P.C. for this reason
Date • Owner
WORKERS' 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 Perfom ance
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 or which this
_j,Ssued.My,yyrlcers' compensation i rice carrier and Rli n bef apermit is
Ca/A'7' Zrtier _ .r%Q policyNumber p( (p 3
_ 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 provis' s.
atelo
Applicant
WARNING: AILURE 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.
I hereby affirm under penalty of perjury that there isENCY
a construction lending agency or the Performance
LENDING Of the work for which this
permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Buildingand Safe for a
1. Each Safety permit subject to the conditions and restrictions set forth on this application.
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, indemnity and hold harmless the City of La Write, 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 dayti from date of issuan
cessation of work for 180 days will subject permit to cancellation. ce of such permit Or
I certify that I have read this application and state that the above info n is I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to a above-mentioned property
/ P perfy for inspection purposes.
"'t ® Signature (Applicant or Agent):