BLCK (04-7572)P.O. Box 1504
78-495 CALLE TAMPICO -
LA QUINTA, CALIFORNIA 92253
BUILDING PERMIT
A
Application Number . . . . .
Property Address
APN:
Application description . . .
Property Zoning . . . . . . .
Application valuation . . . .
BUILDING & SAFETY DEPARTMENT
(760).777-7012
FAX (760) 777-7011
INSPECTION REQUESTS (760) 777-7153
000.0_7.57-2 Date 12/02/04
81120 NATIONAL DR
767-600-003- - -
WALL/FENCE
LOW DENSITY RESIDENTIAL
3075
Owner Contractor
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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
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Permit . . . . . WALL/FENCE PERMIT
Additional desc . .
Permit Fee . . . . 63.00 Plan Check Fee .00
Issue Date . . . . Valuation . . . . 3075
Qty Unit Charge Per Extension
BASE FEE 45.00
2.00 9.0000 THOU :BLDG 2,001-25,000 18.00
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Special Notes and Comments.
123 L.F. 6' GARDEN WALL, CITY STANDARD
Fee summary Charged Paid Credited Due
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Permit Fee Total 63.00 .00 .00 63.00
Plan Check Total .00 .00 .00 .00
Grand Total .63.00 .00 .00 63.00
CL—C 1 0 2� d
P.O. BOX 1504 4 4 ��IIG�
Y7 VOICE (760) 777-7012
78-495 CALLS LIFORNO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: 04' P7572- Date: _ /off r/D� 0�
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
12
Architect or Engineer's Address:
L) /A
Lic. No..
tsUILDING 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
C de, and my License is in full force and effect. �2
� ense Class cense No. 's — �Z O
A 7 -////NLS C 0
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 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 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.).
(--) 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 vers' compensation ipsar2nce carrier a d policy number are:
arder -970.2E /`-t/�y� /Rolicy Number 2:2 OOG 107 3
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 / /v O Ant
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
Lender's Address r�
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 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, def indem ' y and hold harmless the City of La Quinta, its
officers, agents and employees for any act or omission related to the work being performed un er or II mg issuance of this permit.
2. Any permit issued as a result of this application becomes null and v ' wo of comme d wit 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 e i ati is cored. I agree ply W a city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of thi county to en upon the above -menti o ed pro rty r inspection u ose
p rp s.
�V Sid gnature (Applicant or Agent):