9511-003 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am'licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( 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 & Professionals Code).
() I, as owner of the property, am exclusively contracting with licensed
contractors construct the project (Sec. 70 ines &-Prgfessionals Code).
O I am a Section & .'.C. isIrd on
ate-�SignatureofOwner •
WORKER'S 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 & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certiiy 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: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $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.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his 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 agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
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 information is
correct. I. agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
ALCM
-13MILDING PERMIT
PERMIT,i
DATE ' "�A"'
VALUATION uaa►'rr .w v LOT
TRACT
JOB SITE ADDRESS !;3_565 ANg,:N11)A ()BpX, GojN4
APN
OWNER
CONTRACTOR
C?' JNERII I�iLf3.CR
COAC:HELLA VALLEY LAND
78-1 SO CALLF. TAMPICO STE. 230
LA QUWrA CA. 922-53
CBI-#
DESIGNEIVENG[NEER
USE OF PERMIT J`V 1V;B!t4 W
SEWER W?%1WIC11'
FEE DESCRIPTION
FEES
CONTRACT AMOUNT 1.3UU.W LS
EST IWATE D C0.%s i 6F COINS'i'RUC"fl IONI
a,3 3.1ig1
PERMIT FEE SUMMARY
PLUMBING FEE -- SUVER 1.01 -OWI -413-W $30.00
D
NOV p
1
9
15
9
SUB-'rtJl'AL CONS 17RUCrION AND PLAN CHECK
$30.00
LESS PRE -PAID FEES
$0.00
TOTAL, PERMIT V 1..S DUE NOW
$30.00
TOTAL PRO3EC7 I'tiRA1:1T FEES
30.050
RECEIPT
DATE
BV
DATE FINALED
INSPECTOR
INSPECTION RECORD
J OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection // y f
Encapsulation
Gas Piping
Gas Test
Appliances
.✓ODN //
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Received F
Address:
Account N
Service Ad
❑ Meter(s)
❑ Service(s)
❑ :Backflow(s)
❑ House Lateral (s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee
❑ Plan Check Fees Water I Sewer
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
Cash c/, Water Service 'e
Check `%, /
Money Cashier
Order CVWD-438 (11/69)
• 7'
�. n
RECORDING REQUESTED BY
A
AND WHEN RECORDED MAIL THIS DEED AND, UNLESS OTHERWISE
SHOWN BELOW, MAIL TAX STATEMENT TO:
Name
Street BRYAN G. ELSNER AND'
Address RICHARD G. CROCKETT."
Citta 50-949 Washington Street, .Suit
state
Zip La Quin to , ' Ca . 92253 _J
Title Order No. Escrow No.
lE
i a
Grant Deed. SPACE,ABOVE THIS LINE FOR RECORDER'S USE
THE UNDERSIGNED GRANTOR(s).DECLARE(s)
DOCUMENTARY TRANSFER TAXIS $
Parcel'tVo: 7.74-114-013
C )computed on full value of interest orTroperty conveyed, or
(" )computed on Pull value less value of,liens or encumbrances remaining at time of sale; and
FOR A VALUABLE CONSIDERATION, receipt of which is hereby acknowledged,
COACHELLA VALLEY�LAND, a California Limited Partnership
hereby GRANTS.(S) to
BRYAN G. ELSNER, a married man as his, -sole and separaae property as to an
undivided 65 'int'erest•'and RICHARD G.' CROCKETT, a married man as his sole and
separate property; as Tenants in Common.
the following described real property imthe" City of La. Quinta
county of Riverside ; state'of California:
Lot 3 of Block 189 SANTA CARMELITA.AT VALE LA QUINTA, Unit No.19 , as per
map recorded in book 19 ; page(s) 33.-34 of maps, Records of
Riverside County, California.
Dated August 31; 1995
STATE OF CALIFORNIA
COUNTY OF Riverside S.S.
31,.. '...
On August .1995` before me,
Peggy . Ba umgardner,:
a Notary Publid ih and for said'County and State personally'appeared '
Bron r^ .RadakPr �:�.R� �Id:,,:•
Personally known to me (or-��euedsaate.n f atsfastefy
evmk ence). to be the persons) whose names subscribed'to,the
within instrume nd acknowledged to me ilial aheAheyezecuted
same i is er/their authorized. capacl y(i44 and.;that, by
I er/their slgnature(s),,on;the instrument the,peison(s), or the entity
upon behalf of whic a person(s) acted execu{ed the Instrument..
WITNESS my hand Ad official sea4
Signature
HEL_ VALLEY LAND,..a California
Limi d artnersj b .V.L. MANAGEMENT,
INC., Californ c ration
B
y n C. Radaker;:• President
PEGGY BAUMGARDNER
< s COMM. #977321
3: aNotary Public, - Caiifo►nio
RIVERSIDE COUNTY.
..
u+. , MyComm :Ezplre;;NOV,B,IGV6
Peggy/BAuuKjardner
4
MAIL -TAX STATEMENTS TO PARTY SHOWN.'ON FOLLOWING LINE; IF NO PARTY SHOWN. MAIL AS DIRECTED ABOVE
I
F
VALLEY WIDE TUMPIN.G, SERVIbE
100 S. Sunrise Way Suite 133
PALM . SPRINGS, - CA92262'
347-3545
(YO.UW WASTEOIS OUR PROBLEM"
15 F INVOICE GATE OR 1%% INTiKtbt NVILL
1f
i. RECEIVED By - TOTAL
THANK YOU
4'26 a� Contents: 40% Pre -Consumer • 10% Post -Consumer
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