RPL (04-7932)55420 Medallist Dr
04-7932
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 .
. . . , c04=0:0=0:97_9-3=2__--, Date
1/31/05
Property Address . .
. ._ .55420 MEDALLIST DR
APN:
767-510-020- - -
Application description
. . . POOL-- RESIDENTIAL
Property Zoning . . .
. . . . LOW DENSITY RESIDENTIAL
Application valuation
. . . . 28000
Owner
Contractor
NICK GORDON
VICTORIA LANDSCAPES/WATERFALL
55420 MEDALLIST DRIV-p
2365 HIGHWAY 111, SUITE #104
LA.QUINTA ;
A NDIO CA 92201
12005 760),863-3808
W C: EVEREST NTNL
W 3800002849041
08/26/05
G%- Orr
NC E ' .SLB: 801813
12/31/05
------------------------------------
CCC': C27-053
Permit . .
BLDG POOL PERMIT INV.FEE.
Additional desc
Permit Fee . .
543.00 Plan Check Fee
176.48
Issue Date
Valuation
28000
Qty Unit Charge
Per.
Extension
BASE .FEE504
: 00
3.00 13.0000
THOU BLDG 25,001-50,000
39.00
Permit . . . ;MECH POOL
----
Additional desc
Permit Fee
24.00 .,Plan Check Fee6.00
Issue Date . . . .
Valuation . . . .'
0
Expiration Date
7/21/05
Qty Unit Charge
Per
Extension
- BASE FEE
15.00
1.00 9.0000
------------------------------------------------------------------------------
EA_ MECH FURNACE <=100K
9.00
Permit
ELEC POOL PERMIT -RES
Additional desc
Permit Fee . . . .
45.00 Plan Check_ Fee
11.25
Issue Date . . . .
Valuation
0
Expiration Date
7/21/05
Qty Unit Charge
Per
Extension
BASE FEE
15.00
1.00 30.0000
-------------------------
EA ELEC PRIVATE SWIMMING POOL
30.00
Permit . . . . . .
PLUMBING
-----
r
P.O. BOX 1504
78-495 CALLS TAMPICO VOICE (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:
L r Date: 1-31, -95
Applicant: I Architect or Engineer:
Applicant's Mailing Address: O
h
Architect or Engineer' dress:
Lic. No..
tSUILUINU PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I,hereby affirm u etr penalty of a ury that I am licensed u er provisions o Chapter 9 (gwnmencing with Section 7000) of Division 3 of the Business and Professionals
f//Code, and my tens s i f�o d effect.
,license Class License No.
Date/&/Li� Contractor
— 2
OWNER -BUILDER DEC RATION
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
of the work for which this permit is issued.
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
issued. My workers' compensation insurance carrier and policy number are:
Carrier Policy Number
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, agree that, if I should me subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
/ forthwiy� comply with those//pro isiolrs.
to `/ (/� Applicant/
WARN NG: F ILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,D 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 ri
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 ' ornation is correct. I agree to comply with all city and county ordinances and state laws relating to building
COn;(ruction njd here y authorize representatives of this cou�to�enter upon the abov tion roperty for inspection purposes.
Date / Signature (Applicant or Agent). 11
• y
l
Page 2
Application Number . . 04-00007932
Date 1/31/05
Additional desc.. `
Permit Fee 33 .'00 • Plan Check Fee
8.25
Issue Date. ..Valuation
0
Expiration Date 7/21/05 .
Qty. Unit Charge Per
Extension -
BASE BASFEE
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
Special•Notes and.Comments
Ln, POOL/SPA: ALARMS/BARRIERS SHALL
}
4i BE -IN PLACE AT PRE -PLASTER INSPECTION.
;r EQUIPMENT ENCLOSURE'NOT INCLUDED.
asx INVESTIGATION FEE ASSESSED PER UAC 304.5
FOR'WORK.BEGUN WITHOUT A PERMIT.
Fee summary Charged Paid Credited
Due
Permit Fee Total 645.00 .00 .00
645.00
Plan Check Total 201-.98 .00 .00
201".98
Grand Total 8.46.98 - ..00 .00
846.98
FROM FAX NO. Apr. 07 2004 01.42PM r- P2
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