ELEC (04-6769)55375 Medallist Dr
04-6769
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
Application Number
04-00006769 Date 10/13/04
Property Address.
5 537.5 MEDALLIST_DR;_. a
APN:
767-510-0057 - - -
-
'; p ui
Application description -..
Property Zoning . . . .
ELECTRICAL
LOW DENSITY RESIDENTIAL
Application valuation . . . .
a.7
500CJTY
'
-- _-
'
Owner.
A
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Contractor
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NORMAN ESTATES II
NATIONAL CONSTR RENTALS,
INC.
C/O MEDALLIST GOLF DEVELOPMENT
15319 CHATSWORTH STREET
501 NORTH AIA
MISSION HILLS, CA 9.1345
JUPITER, FL.33477
WCC: DOUGHTERY CO
WC: TRJUB4197201
05/01/05
CSLB: 687160-
04/30/.06
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CCC: C10 -C13 -C61 -D31
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Application Number
---------------------------
04-00006769
Permit . . . . . . ELEC-TEMPORARY POWER
Additional desc
Permit Fee 30.00 Plan Check Fee
00
Issue Date
Valuation
0
Qty Unit Charge Per
Extension
BASE FEE
15.00
1.00 15.0000 EA ELEC TEMPORARY POWER POLE
15.00
Fee summary Charged
Paid Credited
Due
Permit Fee Total 30.00
.00 .00
'30.00
Plan Check Total- .00
.00 .00
.00
Grand Total 30.00
.00 .00
30.00
P.O. Box 1504
78-495 CALLS TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number: .0 '—
Applicant:
Applicant's Mailing Address:
VOICE (760)777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date: 10- /. • f
Architect or Engineer:
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 provisions of Chapter (commencing with Section 7000) of Division 3 of the Business and Professionals
Code, and my Lic6n full force and effect.
License Class f/% License No.
Date l _0 Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am ex mptfrom t tractors' 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, . ve, 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
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.
I have and will mai in workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
ie rae c mpensation insurance carrier and policy numbe e:
Carrier (L Policy Number
_ I certify that, in the performance of the work for which th s eftnft is isgue-d, I s ploy any person in any manner so as to become subject to the workers'
compensation laws of Califomia that, if I should become subject to t orkers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with thos rovisions.
Date l3 G Appli nt
WARNING: FAILURE TO SECURE W ERS' 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
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 pe '
2. Any permit issued as a result of this application becomes null and void if wo ' o co menced witZ'cou
;from date o ' uance 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 ect. I agree comply with adinances and state laws relating to building
construction, and hereby authorize representatives of this county to enter u the above -me Toned ofooertneoe
Date `(J 4 Signature (Applicant or Agent):