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RPL (04-5622)55215 Medallist Dr 04-5622 BUILDING- & SAFETY DEPARTMENT v P.O. BOX 1504-701 kQ,fOF9 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number 04=000056:22 Date 7/22/04 Property Address . . . . . . 55215 MEDALLIST DFS API: 767-510-001 L1 Application description_. POOL --1 - -u Property Zoning . . . LOW DENSITY RESIDENTIAL i Application valuation . . .17000 U J1jL 262004 Owner Contractor_ CITYOFLAQUINTA NORMAN ESTATES II CALIFORNIA POOLS & SPAS C/O MEDALLIST GOLF DEVELOPMENT P.O. BOX 1280 501 NORTH AlA COACHELLA CA 92236 JUPITER FL 33477 (760) 398-9222 WCC STATE FUND WC: 04600061168 01/01/05 CSLB: 656128 10/31/04 CCC: t C8 -C27 -C29-053 Permit . . BLDG POOL PERMIT ,,Additional desc Permit Fee 180.00 Plan Check Fee 117.00 Issue Date . . . . Valuation . . .16459 Qty Unit Charge Per.Extension BASE FEE 45.00 15.00- 9.0000 THOU 'BLDG 2,001'-25,000 135.00 ----------------------------------------------------------------------------- Permit MECH POOL Additional desc Permit Fee . . . . 24.00 Plan.Check,Fee 6.00 Issue Date.'. Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE .15. 00 1.00 9.0000 EA MECH FURNACE <=100K .9.00 ---------------------------------------------------------------------------= Permit . . . . . . ELEC POOL PERMIT -RES Additional desc Permit Fee 45.00 Plan Check Fee .11.25 Issue Date . . . Valuation . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 P.O. BOX 1504 • • VOICE (760) 777-70:2, 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 4 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 0 Date: Applicant: I Architect or Engineer: Applicant's Mailing Address: Architect or Engineer's Address: Lic. No.. bUILUING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed underp rovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals C and my Lice?p is in f 11 force and effect. / N � Z� icense Class C_ S License Date -7-1,-2 6 1,o ge / - <eC.n�' NER-BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from ttors'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, 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 that 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).): U 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 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 for 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 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 performance of the work for which this permit is issued. -A-I have and will maintain workers' compensate n insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is iss ed. My worke�compensation ' rance carrier ani Pole�y Aumbel are: Camerp GwAl ( olicy Number t/(�CJC)� (O 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 tha(, if mould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with those provisions. rr / J WARNING: FAILURE TO SECURE WORKERS' COM TI 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. 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 A - Lender's Address {� 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 Eenti enced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. 1 certify that I have read this application and state that the above information is correcply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to enter upon the property for inspection purposes. ate f 2 Si! 9nature (Applicant or Agent): Page 2 Application Number . . . . . 04-00005622 Date 7/22/04 Qty Unit Charge Per r Extension 1.00 30.0000 ----------------------------------------------------------------------------- -EA ELEC PRIVATE SWIMMING POOL 30.00 Permit . . . . . . PLUMBING Additional desc Permit Fee . . . 33.00 Plan Check Fee 8.25 Issue Date Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 2.00 6.0000 EA PLB FIXTURE 12.00 1.00 3.0000 EA PLB WATER INST/ALT/REP.. 3,.00 1.00 3.0000 EA PLB GAS PIPE 1-4 OUTLETS 3.00 Permit . . . . . . WALL/FENCE PERMIT Additional desc'. Permit Fee . . . 17.00 Plan Check Fee .00 Issue Date . . . . Valuation . . . 541 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 2.0000 ----------------------------------------- HND BLDG 501-2,000 2.00 Special Notes and Comments ----------------------------------- POOL/SPA, 25 L.F. 5' BLOCK WALL, CITY- ITYSTANDARD. STANDARD.ALARMS/BARRIERS SHALL BE IN PLACE AT PRE -PLASTER INSPECTION Fee summary Charged Paid Credited Due Permit Fee Total 299.00 .00 .00 299.00 Plan Check Total 142.50 .00 .00 142.50 Grand Total 441.50 00 .00 441.50