9510-052 (BLCK) ALCM N BUILDING PERMIT PERMIT
cA LICENSED CONTRACTOR DECLARATION ` 5111-4}S2
N I hereby affirm that I am licensed under provisions of Chapter 9(commencing with DATE VI1W.'J'� VALUATION .4fE LOT x TRACT
r LLI Section 7000) of Division 3 of the Business and�Professionals Code, and my APN
O =) co JOB SITE ADDRESS
r` C7 Lr) License is in full force and effect. 280103 49.641 AVILA
r- W License# Lic.Class Exp.Date
cc OWNER CONTRACTOR
n I• Date/,n SignatureofContractor /: .a_,_.c. /� t Crl?ll'9f.n- W. CONS°I OC1 ON
O IIsItRY fl I��UItN P.O.I3t1X 2464'
ca — OWNER-BUILDER DECLARATION
284
J U 1 hereby affirm that I am exempt from the Contractor's License Law for the 49-641 AVILA YUCCA VALLEY CA 9,
a following reason: LA,QUINIACA. 92253 61932M,14. CI3I#
07 ( ) I, as owner of the property, or my employees with wages as their sole 6197713$12 DESIGNERIENGINEER
Z compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). !'r zMR11u.If'Rea.," 41116
( ) I, as owner of the property, am exclusively contracting with licensed USE OF PERMIT
' contractors to construct the project(Sec.7044,Business&Professionals Code). 22 Olt;4'AKJ13(JAW)EN BLOCk W A1..L
( ) I am exempt under Section B&P.C.for this reason
L , Date Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION FEE DESCRIPTION FEES
CL Q I hereby affirm under penalty of perjury one of the following declarations: 4 141. WA" Z2.VU Lti
o 2 Z ( ) I have and will maintain a certificate of consent to self-insure for workers'
Lo gO compensation, as provided'for by Section 3700 of the Labor Code, for the
X W LL. perfor a/nce of the work for which this permit is issued.
p J J (have and will maintain workers'compensation insurance,as required by
00 Q U Section 3700 of the Labor Code,for the performance of the work for which this
p U permit is issued. My workers'compensation insurance carrier&policy no. are:
d Carrier Policy No. '7 i Ei7(El�COST OF Zt�NS�'RUMON1
It Z (This section need not be completed if the permit valuation is for$100.00 or less). 111h;HMIT F1i1P Si)!slMAIRY
CC) :) ( ) 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
J= 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 SUB-".!'f3T.AL CONSTRUC"Il•ON AND PLAN CHECK. $15.00
&hold harmless the City of Indian Wells,its officers,agents and employees. LESS PRF-PAID FEES 50.00
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 TOTAL PERMIT 1:IMS DUE:NEW $15.00
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 TOTAL Jt RO,';FCT P I?`IMN--U i'FT'J'.S 15.00
correct. I agree to comply with all City, and,State laws relating to the building IIIIIIII III I VIII IIIIII
construction,and hereby authoriie representatives of this'City to enter upon the 65
• above-mentioned property for inspection purpolses. IE
nature (Owner/Agent) `f i Data %/� / RECEIPT DATE BY } JDT NALE INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings Ducts
Stab 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 Wail 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 Pibg.Test
Final Gas Piping
PLUMBING APPROVA S Gas Test
Electric Final
Waste Lines Heater Final
Water Piping lumbing Final
Plumbing Top Out Eligipment Enclosure
Shower Pans O.K. or Finish Plaster
Sewer Lateral Pool Cqver
Sewer Connection Encaps ation
Gas Piping
Gas Test
Appliances
Final
COMM NTS:
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)