9603-0030 (RPL)79080 Arbola Circle
LICENSED CONTRACTOR DECLARATION
ALC BUILDING PERMIT PERMIT t tQ :sta
N 'r hereby affirm that I am licensed under provisions of Chapter 9(commencing with DATE 1517/96 VALUATION .1%J2 KJ0.t 1 LOT TRACT
W Section 7000),•of;Division 3 of the Business and Pofessionels Code, and rn
C) c License is Irl.full'force and effect. " , ;_y R - JOB SITE ADDRESS70-080 ARROLA , APN
n W Ucense Lic.Clash Date
Date 43 IZ G Signatureof Contractor OWNER CONTRACTOR
r.
Q, Z I I MA:STFR.POC LIS
fti't;T n.lr'iT.fl 1' 7'2.64 tt%iry J 9 i
cD H 6 OWNER-BUILDER DECLARATION srA. .d l V..11 r.r,.vJ It V & 3..1
J U - I hereby affirm that I am',exempt from the Contractor's License Law for the 7M80.E RSOLA4.:_iR. t 4 PALM DESERT CA 922.60
► d following reason: i,,Q (619) 1f-6'1 fS 16
U) ( ) I, as owner of the property, or my employees with wages as their sole
Z compensation,will do the work,and the structure is not intended or offered for ;DESIGNER/ENGINEER
sale (Sec.7044,Business&Professionals Code).
O I, as owner of the property,"am exclusively contracting with licensed USE OF PERttuI'tit7l..r1Pd.ia`(7f 41',1.
r contractors to construct the project(Sec.7044,Business&Professionals Code).in
O I exe pt under Section .)or this reason P:oE&-,qla
NDate I Signature oftJwner
1 OU rn WORKER'S COMPENSATION DECLARATION FEE DESCRIPTION FEES
0Q I hereby affirm under penalty of perjury one of the following declarations: t. j0 A fat jK SPA 12,000.00 LS
1 0 M Z ( ) I have and will maintain a certificate of consent to self-insure for workers' ti
Lo HO cc compensation, as provided for by Section 3700 of the Labor Code, for the,. 4 c
X W LL. performance of the work for which this permit is issued.
p J J ( ) I have and will maintain workers'compensation insurance,as required by 'S
C0 Q U Section 3700 of the Labor Code,for the performance of the work for which this ,
(J permit is issued. My workers'compensation insurance carrier&policy no. are:
d LO Carrier I.ACI(At Policy No. NWC311024-1011) f&-r1MA`t'90 CONT Or CO?N-WrRUC'!!100 t4Qt)t ml?
I Z (This section need not be completed if the permit valuation is for$100.00 or less). FERMIrt 1H EE SUMMARY ,.
00 Q ( ) I certify that in the performance of the work for which this permit is issued, PLAN Cfl: t;K.-1?,E 1.01.000-43`9-3.18 &97.76
CY I shall not employ any person in any manner so as to become subject to the n-
ce.rls 'F .vC•r1oN 1OI -418-oo0 $135.00
workers' compensation laws of Californi d agree that if I should become t "1 ()00 $ErM1 ttu co
arl MG CMA:ttl1;CAL r L.--1ti DI, 101-000-42 -
subject to the workers' compensation pr vis' p ns-of Sect'o 3700 of the Labor
Code, I s all f with comply with 'ose( rodislons. i7GCt;.t? i1CA1, -
POOLi.f)1-f)flf)-Q2A-Q(30 $<i5.00
PLt MB1140 FEE--POOL 1114-1)t1U-4:49-600 $27.00 !'
"xDate• I*Z.. Applicant Q •
Warning:Failure to secure Workers'Compensation coverage is unlawful and shall f
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.. j
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 at44
y
whose request and for whose benefit work is performed under or pursuant to SUI;-TOTAL CONS1'R.UMONT VI,U,PLAN CHECK $318:18-
any
;318` ...any permit issued as a result of this application agrees to,&shall, indemnify LESS PRE"-P,,A W FEES $0.00
&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 TOT.A#.,PIti;RA UT FEES NOW $318.75
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 1,011 ,and State laws relating to the building
11 construction,and hereby author' representatives of this City to enter upon the I IIIIIII VIII III VIII IIII 36
• above-mentioned property fo i spectio urpo s ..
' IE
1' Signature (Owner/A9er
Date VfIJ RECEIPT DATE BY DAT NALE —INSPECTOR'S
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE 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 Encapsulation
Gas Piping
Gas Test
Appliances
Final 1717
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
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AND ALL APPLICABLE CODES
DATE
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