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BLCK (04-7556)55380 Medallist Dr 04-7556 BUILDING & SAFETY DEPARTMENT P.O. BOX 1504 ,. (760).777-7012 78-495 CALLE TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT Application Number . . . . . Property Address . . . . . APN: Application description . . . Property Zoning . . . . . . Application valuation . . . . X04= 0 56 Date 12/02/04 55380. MEDALLIST DR 767-600-001- - - WALL/FENCE LOW DENSITY RESIDENTIAL 2825 Owner Contractor MEDALLIST DEVELOPMENT EHLINE COMPANY 1070 E. INDIANTOWN RD 55375 MEDALLIST DR JUPITER FL 33477 LA QUINTA CA -92253 (760) 771-8130 WCC: STATE FUND WC: 2290006783 01/01/05 CSLB: 482086 11/30/05 CCC: B ---------------------------------------------------------------------------- Permit . . . WALL/FENCE PERMIT Additional desc Permit Fee 54.00 Plan Check Fee .00 Issue Date . . Va]uatinn Qty Unit Charge Per Extension BASE FEE :s 45.00 1.00 9.0000 THOU BLDG.2,001-.25,000 9.00 --------------------------------------------=------------------------------- Special Notes and Comments 113 L..F. 6' GARDEN WALL, CITY STANDARD Fee summary Charged ----------------- ---------- Permit Fee Total 54.00 Plan Check Total .00 Grand Total 54.00 Paid Credited Due ---------- ---------- ---------- .00 .00 54.00 .00 .00 .00 :00 .00 54.00 SEC 10 2r: P.O. BOX 1504 • " VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 LA Qu[NTa, CALIFORNIA 92253 4 4 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 017- 155(- Date: /a • /y.0 Applicant: I Architect or Engineer: Applicant's Mailing Address: Architect or Engineer's Address: W1A Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License. .n full force and effect. ,,-'License Classicense Zf d .Ze->C — Ery/ %✓ G'v 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 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. 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 c r ismd. My wrkers' compensatiorDasurance carrier and licy number ar : /Carrier // I/s ft!/1-do Policy Number 22-ytDG p jkA _ 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, 1 shall forthwith comply with those provisions. DateZ2 e V APpI &'1'/i/✓4-__ CID WARNING: FAILURE 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. 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 cancel I certify that I have read this application and state that the inf ation is rrect. I agree o mpl ' 'all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of th' count t enter upon a above -me do property for inspection purposes. 044 ! Signature (Applicant or Agent):