04-5267 (RPL)55535 Medallist Dr
04-5267
BUILDING &.SAFETY DEPARTMENT
P.O. BOX 1504
(760).777-.7012
78-495. CALLE TAM.PWO FAX (760) 777-7011
LA QUINTA, CALIFORNIA- 02253 INSPECTION REQUESTS .(760) 777-7153
BUILDING PERMIT
Application Number* :::: O4-- 0_CF0 0 5 2 6_7 Date -6/30'/04
Property Address 5553_ _MtDALLIST DR.
APN: 767 -510 -009 -
Application' description -POOL -'RESIDENTIAL
Property Zoning. LOW DENSITY RESIDENTIAL
Application 16000
Owner Contractor
7 - - - - - - --- - - --- - --- - --- - - - - -- - - - - - - - --- - - - - ---
NORMAN ESTATES IICALIFORNIA 'POOLS SPAS
..C/O. MEDALLIST. '.*.GOLF DEVELOPMENTP-. 0. . BOX' 12 8 0
.5,01: NORTH. AlA' COACHELLA
CA' 9223%6
..'JUPITER'. FL.33477 (760) 398-9222.'
WCC: STATE FUND
WC 046000.611-68,..: .01/01/05
CSLB,.':.. .65 -10./31/04'
. 6'12 8
......C -27'-C29-
CCC:.: C8-
7 - - - - - - - - -- - --- - 7 - - --- - - - - - - - - - -
Permit . . . . . . BLDG POOL PERMIT
Additional desc-
Pormit-Fee, . . . . 171.001 Plan Check Fee .111,15
Is'sue Date Valuation 16,000
Qty Unit Charg.p... Per - Extension
.BASE :FEE 45..0.0
14.. 0O 9:0000 THOU BLDG'. 2.,001-25,000 12.6.00
--------------- ---------------
Permiit MECH POOL
Additional desc.
Permit Fee 24 00. P lan. - Check, ,Fee 6.00
.
%lssue-Date Valuation 0
Qty Unit Charge Per Extension
BASE -FEE 15..00
.1-.00 .9.0000' EA. MECH FURNACE <='100.K. 9.00
-------------------------------------------------- --------------------------------
Permit . . . . . . ELEC POOL-PERMIT=RES
Additional desc
Permit.Fee 45.00. Plan Check
Fe-(9
.11.25
issue..Date.. a I uR 5
V -ion 0
Qty.'. Unit Charge Per Extension
BASE FEE- C OF 15-00
VVI
1
P.O. Box 1504 - • �����
79-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
Applicant's Mailing Address:
VOICE'(760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
a
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm under penalty of perjury that 1 am licensed under pro ' ' of Chapter 9 (commencing with section 7000) of Division 3 of the Business and. Professionals
fie, and mY Lice p�e is.ir fuloroe Hnd effect
/ License Clas*s [_tS Licen
Date'4A 44
L Gor
4WN-BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the'State License Law for the followi reasoncity or county that requires a perinit to construct, alter, i n9 (Sec. icesth ,Business and Professions Code: Any
mprove, drepair any structure, prior to Its issuance. also requires the applicant for the permit to fie a signed
statement that he or she Is licensed pursuant to the provisions of the Contractors• State Ucense 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 es their sole compensation, will do the work, and the stricture Is not Intended or offered for sate (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, twwever, 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.).
(, i, as owner of the property, am exclusively contracting with licensed contractors to oonstruct 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.).
.(_) I am exempt under Sec. BA P.C. for this reason
Date Owner.
I thereby affirm under penaltyof WORKERS' COMPENSATION DECLARATION
perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self4nsure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the
.perfamance "
4of the work for which this k is issued.
1 have and will, maintain wo ' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is
/ su d. w cars' ce •nSa6�rance ca ' r cy nu r Z
/gamer. Policy Number (9
_ I certi fy that, n t e perfornaihce of tiework for wtd s permit issued, l shall not employ any person in any.manner so as to become subject to the workers'
compensation laws of California, and= that, I Id subject to the workers' compensation provisions of Section 3700 of the Labor Code, l shall
forthwith comply with those sions:
WARNING: FAILURE TO SECURE WO*ERS' COMPE-M6ON C VERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ), 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
Lendefs Address PIA
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 uest 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 , and shall, defend, indemnify and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to tl)e work bei rn under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work t comme within 180 days from date of issuance of such permit, or
cessation of work for 180 days will subject permit to cancellation.
1 certify that 1 have read this application and state that the above int tion is rrect. I g to com y with all city and county ordinances and state laws relating to building
construction, and hereby authorize.representatives of this county a ter upon abo property for inspection purposes.
ate .�0-_Signtue (Applicant or Agent):
.
C
Page 2
Application Number . . . 04-00005267
Date 6/30/04
Qty Unit Charge Per
Extension
1.00 30.0000 EA ELEC
PRIVATE SWIMMING POOL
30.00
Permit . . . . PLUMBING
Additional desc
Permit Fee 33.00
Plan Check. Fee
8.25
Issue Date . . . .
Valuation
0
Qty Unit Charge Per
Extension
BASE
FEE
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
POOL/SPA. ALARMS/BARRIERS SHALL
BE.IN
PLACE AT PRE -PLASTER -INSPECTION.
EQUIPMENT ENCLOSURE NOT INCLUDED
Fee summary. Charged
Paid Credited
Due
Permit Fee Total 273.00
.00 .00
273.00
Plan Check Total 136.65
.00 .00
136.65
Grand Total 409.65
.00 .00
409.65
i
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