RPL (04-5603)55335 Medallist Dr
04-5603
BUILDING & SAFETY DEPARTMENT
P.O. Box 1504
(760).777-7012
78-495 CALLS TAMPICo FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153
BUILDING PERMIT
Application Number
04=,0_00056Q3 Date
7/22/:04
Property Address . .
. . . 55335 MEDALLIST DR
APN:
767-510-004- - -
Application description
. . . POOL - RESIDENTIAL
Property Zoning . . ...
. . . LOW DENSITY RESIDENTIAL
Application valuation
. . . . 17000'
Owner
Contractor
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: C8 -C27 -C29-053
-----------.--------------
Permit . . .
------------------------------
MECH POOL
Additional desc
Permit Pee.
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 . . . .'. . .
BLDG POOL PERMIT
Additional desc
Permit Fee. . . . ..
180.00. Plan Check Fee
117.00
Issue Date
Valuation
17000
.Qty .-Unit Charge
Per
Extension
BASE FEE
45.00
15.00 .9.0000
THOU BLDG 2,001-25,000
135.00
--------------------------
`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) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 061- 5603 Date:
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 perjury that I am licensed under p visions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
de, m and my Lice is I. rce and effect.
License Class —
--15 n No.
mate L J C'Y/Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of 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 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 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 performance
Kof the work for which this permit is issued.
I have and will maintain rkers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is ed. workers' ompensation i nce carrier a/pp'd pplicy number
er olicy Number 0`7C OUl ( Ik_
_ I certify that, in the p rformance of the work for which is ermit 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, i s ould me subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
/Bate -7/.2/,/,02 plicant
WARNING: FAILURE TO SECURE WORK RS' COMPE SATIO 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
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 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 cor ct. aC
y with all city and county ordinances and state laws relating to building
construction, and herebyauthorizerepresentatives of this county nter upon abo e-operty for inspection purposes.
/ate 7/011--1 O/ ature (Applicant or Agent):
{ •tA• µJG G . ,t �: '• .VI - A' ...
_
Page 2
Application Number .04-00005603
Date 7/22./04
Qty. Unit Charge. Per
Extension
1.00 30.0000 EA ELEC PRIVATE SWIMMING POOL
30.00
Permit . . . . PLUMBING
Additional desc
Permit. --Fee 33.00 P1an,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_
------------------7---7-----------
J` Special Notes and Comments
POOL/SPA. ALARMS/BARRIERS SHALL BE IN
PLACE AT PRE -PLASTER INSPECTION.
EQUIPMENT ENCLOSURE NOT INCLUDED
Fee summary Charged Paid Credited
Due
Permit Fee Total 282.00 .00 00
282.00
Plan Check Total 142.50 .00 .00
142.50
Grand Total 424.50 .00 .,00
424.50
:
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