BLCK (04-5163)55295 Medallist Dr
04-5163
BOX 1504.: (760);777-7012
.,-OF'fi9 78 4;95 CALLS TAMPIC.O FAX (760) 777-7011
LA Q.UINTA.,'CALIFORNIA 92253 INSPECTION REQUESTS (760).777-7153 .
BUILDING PERMIT
Application Number 04 000.05163-- ' Date.. 6/25/04 .
'Property. Address . . . . 55295 MEDALLIST DR
APN:: 767-51Q-003-
Application- description''.'WALL/FENCE
Property Zoning LOW DENSITY RESIDENTIAL-
Applicat.ion valuation 3440..:
Owner Contractor.
NORMAN ESTATES II 'EHLINE COMPANY
.0/O MEDALLIST GOLF DEVELOPMENT 55375 MEDALLIST DR:
501 `NORTH A1A. LSAQULNTA CA. 92253.
JUPITER, :.:.:, FL :33477. (7.60) _77.1:-8:1'30
WCC: STATE FUND.:.
WC
. _ -2290006783 0.1./01/.05
CSLB: 4,82..0.86: 11%30/05
CCC:-- -B
- -- - - - - - - - --- - - - - - - - - -
Permit. WALL/FENCE PERMIT `
Additional desc
Permit Fee 63.00 Plan Check.Fee ..00
Issue Date Valuation.. 34.40.
Qty Unit Char e Per Extension
9.
BASE . FEE'.... 45.:00
2.00. 9. 0000 THOU.. BLDG .2, 001=25., 000 '.`.:, 18.00-
Special
8.00-Special Notes and Commerits
40 L.F. 3' BLOCK WALL, 112 L.F. 6' BLOCK
WALL, BOTH ORC.O SYSTEM.
Fee summary ,,Charged Paid Credited Due.
Permit -Fee Total 6`3.00 '.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 922.53
BUILDING & SAFETY DEPARTMENT
VOICE (.760) 777-7012.
FAX (760) 777-7011
INSPECTIONS (700)'777-7153
Application Number: 5/(o j Date: '(a - $ >p y
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT.DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of pequry that l am licensed ;1cenerNo.—
derpproisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
Liesand my Li is in full force and effect. fo
License Class_ I syo 2
Date (0C' ontrector
OWNER -BUILDER DECLARATION
I hereby affirm'under penalty of perjury that I am exempt from the Contractors' State License Law for the.foltowing.reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to+ construct atter, 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 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
himselfor 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 constrict 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 contractors) 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 selfAnsure 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.
Y` I 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
is ed. My wqikers,com ensation psur nce carrier andel oil number ark,
Caner / iJ w%t /Pollcy Numb( NO
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 provislohs.
WARNING: FAILURE TO SECURE WCYkERS' 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.
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 r
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 harnless the City of La Qulnta, 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 days from date of Issuance of such permit, or
cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above Info 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 county to t upo above-mentioned property for Inspection purposes.
Date `-' Signature (Applicant or Agent):