BLCK (04-7564)55540 Medallist Dr
04-7564
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 - 04=000075.647. Date. 12/.02/04
Property Address . . . . . 55540 MEDALLIST DR
APN: 767-510-017- - -
Application description WALL/FENCE
Property Zoning . . . . LOW DENSITY RESIDENTIAL
Application valuation . . . . 2975
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 Valuation 2975
Qty Unit Charge, Per Extension
- BASE FEE X45.00
1.00 9.0000 THOU. BLDG 2,001-25.,000 9:00
Special Notes and Comments
.119 L.F. 6' GARDEN -WALL, CITY STANDARD
Fee summary Charged Paid Credited Due
Permit Fee Total 54.00 .00 .00 54.00
Plan Check Total .00 .00 .00 .00
Grand Total 54.00 .00 .00 54.00
DEC 1 23A
C11 7
r,1N VCEOFr'T.
P.O. BOX 1504
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
BUILDING & SAFETY DEPARTMENT
Application Number: D
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
VOICE (760) 777-7012
FAX (760) 777-7011
INSPECTIONS (760) 777-7153
Date:
Architect or Engineer's Address:
Lic. No.:
LDING 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
Cade, and my License i 4n full force and effect.
l rise Class ,9 icense No.
6ate% O OCo E% • iy G
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. , B.& 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
vv Y 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
issued. My workers' compensation ' ce carrier and -policy number are:
,-6-mer olicy 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, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions.
,,-`Date / C>/.,>
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 a
Lender's Address T
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 b!.P!
id if work is not commen d within 180 days from date of issuance of such permit, or
cessation of work for 180 days will subject permit
I certify that I have read this application and state that the aborrect. I ree to com y it i y and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this he above -m tioned ro y for inspection purposes.
Date/2 l0 & Si (Applicant or ent):