BLCK (05-4685)55380 Medallist Dr
05-4685
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
Application Number: C05 -00-0-04685J
Property Address: 55380 MEDALLIST DR
APN:. 767-600-001- -
Application description: WALL/FENCE
Property Zoning: LOW DENSITY RESIDENTIAL
Application valuation: 742
T4ht 4 4Q".
Architect or Engineer:.
air
BUILDING &.SAFETY DEPARTMENT
BUILDING PERMIT
Owner:
JEFFREY TALLMAN
55380 MEDALLIST DR
-LA QUINTA, CA 92253
Contractor:
ALPINE SERVICES
P.O. BOX 4687
PALM DESERT., CA 9226
(760)346-2350
Lic. No.: 786324
VOICE (760) 777 -7012 -
FAX (760) 777-7011
INSPECTIONS (760) 77777153
Date: 10/17/05
OCT 7 2005 ID
CITY OF LA QUINTA
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LICENSED CONTRACTOR'S DECLARATION -
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with
I hereby affirm under penalty of perjury one of the following declarations:
Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect.
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided
License Class: C53 License No.: 786324
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
ntractor:
issued.
-4I 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 issued. My workers' compensation
OW E BUI R DECLARATION
insurance carrier and policy number are:
I hereby affirm under penalty of perj r that I am e m from he Contractor's State License Law for the
Carrier STATE FUND- Policy Number 2290023236
following reason (Sec. 7031 .5, Busi s and Profes s Code: Any city or county that requires a permit to
_ I certify that, in the performance of the work for which this permit is issued, I shall not employ any
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the
person in any manner so as to become subject to the workers' compensation laws of California,
permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's State
and agree that, if I should become subjecttothe wor{{ers' compensation provisions of Section
License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3700 of the Labor Code, I shall forthwith comply w' li those provisions.
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).: -
4i 17 os
Date: ant:
(_ 1 1, 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
WARNING: FAILURE TO SECUR ORKERS' C S ION OVERAGE IS UNLAWFUL, AND SHALL
Contractors' State License Law does not apply to an owner of property who builds or improves thereon,
SUBJECT AN EMPLOYER TO CRI AL PENALT ES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND
and who does the work himself or herself through his or her own employees, provided that the
DOLLARS ($100;000). IN AODI N TO THE CO OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
improvements are not intended or offered for sale. If, however, the building or improvement is sold within
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
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.).
(_) 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.).
(_) I am exempt under Sec: , BAP.C. for this reason
Date: Owner:
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:
LQPERMIT
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 correct. gree to comply with all
city and county ordinances and state laws relating to building construction, and hereby orize representatives
of this county to enter upon the a ve-mentioned prey for ins io purpqises.
Application Number . . . 05-00004685
•
Permit . . WALL/FENCE PERMIT
Additional desc .
Permit Fee 21.00 Plan Check
Fee
.00
Issue Date Valuation
742
Expiration Date 4/15/06 .
Qty Unit Charge Per
Extension
-BASE' FEE
15.00
3.00 2.0000 HND BLDG 501-2,000
6.00"
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Special Notes and Comments
22•L.F. 6' GARDEN WALL, 1116" 4' GARDEN
WALL, 41 L.F. OF < 36" GARDEN WALL, ALL
CITY STANDARD
Fee summary Charged Paid Credited
Due
Permit Fee Total 21.00 .'00
.00
21.00
Plan Check Total .00 ..00
00
.00
Grand Total '21.00 .00
.00.
21.00
i
Bin # .
City of La Quinta
Building a Safety Division
P.O. Box 1504, 78=495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking
g Sheet
Permit #.
_
Project Address: '5 53
Owner's Name: V
A. P. Number:
ddress+
Address:-'-
Legal
Legal Description:
City, ST, Zip: L 0011V 74-
-Contractor
S
_
Telephone yQ, •73
'
Address:7l S G. 5'i/76,L3
Project Description:
City, ST, Zip: ( -T
Telephone: 6600D D ` 2, SDz
o
2- 1-, ! ' U '
-State
City Lic. #:
V6 I
Arch., Engr.,.Designer:
r
Address:
1 F, ( Of— LES
City, ST, Zip:
Telephone:
Construction Type: Occupancy:
State Lic. #:
Project type (circle one): New Add'n Alter Repair Demo
Name, of Contact Person:.
Sq. Ft.:#Stories:
# Units:
Telephone # of Contact Person:
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING .
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''d Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
-
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees