BLCK (04-5167)55455 Medallist Dr
04-5167
BUILDING & SAFETY DEPARTMENT
P.O. Box 1504.
_ (760)1777-7012
FTE78 49`5\CALLE TAMPIC.O FAX (76 0) 777-701.1
QuINTA: CALIFORNIA 92253 INSPECTION REQUESTS (760).777-7153 .
s;a 1 8 , ` BUILDING PERMIT
Appli""caEtion Number 00
04 00-5167- ; Dat.e. 6/25/04 .
Property.Address 55455 MEDALLIST DR
APN 767 -510 -007 -
Application description_. 'WALL/FENCE
Property Zoning LOW DENSITY RESIDENTIAL.
Application valuation 4020.
Owner Contractor
NORMAN ESTATES II EHLINE COMPANY
,,.0/O MEDALLIST GOLF DEVELOPMENT . 55375 MEDALLIST.DR
501 NORTH AIA, LA.QUINTA CA. 92253_
JUPITER...'..';-:. FL 3347.7. (7.60) 771-8130
WCC: • STATE FUND.
WC.:..:... 22900067.8.3 01/01/05
CSi;B: 4:82.086: 11/30/05
CCC: B
Permit. WALL/FENCE PERMIT `
Additional desc
Permit Fee 72.00 Plan Check Fee 00
Issue Date Valuation. 4020
Qty Unit Charge Per Extension
BASE FEE 4 5. 0'0
3.00.. 9.000'0 THOU. BLDG.2,001:=25.,000 22...00
------------
6.
Special Notes and Comments
20 L.F. 3' BLOCK WALL, 148 L.F. 6' BLOCK 1
WALL, BOTH ORCO SYSTEM
Fee summary ,..Charged Paid Credited Due.
Permit Fee Total 72:00 ,00 .00 72..00
PlariCheck Total 00 00 00 00
Grand To .72.00 .00. .00 72.00
P.O. BOX 1504 r
VOICE (.760) 777-7012.
78-495 CALLS TAMPICO FAX (760) 777-7011•
LA QUINTA, CALIFORNIA 922.53 INSPECTIONS (760).777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: io (0 7 Date: o ' •
Applicant: I Architect or Engineer.
Applicant's Mailing Address:
Architect or Engineer's Address:
Lic. No.:
A-
BUILDING PERMIT.DECLARATIONS'
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that'l am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
Cosies and ss Licer_s is in full force and effect. / qg o 6 .
cense Class J -[kens, No. O
OWNER -BUILDER DECLARATION
I hereby affirm'under penalty of perjury that I am exempt from the Contractors' State License Law for the.Mlowing.reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a perrnit 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 rive 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 constrict 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 contractors) 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
hereby affirm under penalty of perjury one of the following declarafions:.
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
t yy of the work for which this permit is issued.
1^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
ttssssuu d. My wor com ensation iosarafice caner, m ofjcy num er are•
anter o `i %s h n old icy Number G W A pp
—I certify that, in the performance of the work for which this, permit is Issued, I shallnotemploy.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' compensadon provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisigFq.
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 3708 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.).
Lenders Name
Lenders 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 forthon 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 Quanta, 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 wail subject permit to cancellation. J
1 certify that 1 have read this application and state that the above Info don is correct. I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to pon the above-mentioned property for Inspection purposes.
bate tem 2 Sure (Applicant or Agent):