9602-054 (INTERIOR DEMO) LICENSED CONTRACTOR DECLARATION ALC0 BUILDING PERMIT PERM"402-05-4
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� 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with DATE r WTO VALUATION 5►.� LOT TRACT
C W Section 7000) of Division 3 of the Business and Professionals Code, and my
O :) co JOB SITE ADDRESS APN
License is in full force and effect. Sil-150 AirGXUE 50 769-L70-020
N a: License# LIC.Class Exp.Date OWNER CONTRACTOR
Z Date Signature of Contractor OWNF�R![31JILDER
CDP OWNER-BUILDER DECLARATION )c@ Vi'AI�'DA REE SE
J IU 1 hereby affirm that I am exempt from the Contractor's License Law for the 6020;1 AVENUE `10
a following reason: 1NDIO CA 92201 (_1311tt
Z (,),�'1,'as owner of the property, or my employees with wages as their sole (6191164-3(.80 DESIGNERIENGINEER
compensation,will do the work,and the structure is not intended or offered for
sale (Sec.7044, Business&Professionals Code). USE OFPERMITlLir1Vt.1liViv
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business&Professionals Code).
( ) I am exempt under Section B&P.C,for this reason 1N'I*IMJUR 00\40LITION
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/Date ^.r.f Signature of Owner
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rn WORKER'S COMPENSATION DECLARATION FEE DESCRIPTION FEES
dQ I hereby affirm under penalty of perjury one of the following declarations:
02 Z ( ) I have and will maintain a certificate of consent to self-insure for workers'
LO H OIr compensation, as provided for by Section 3700 of the Labor Code, for the
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
03 Q U Section 3700 of the Labor Code,for the performance of the work for which this
C5 U permit is issued. My workers'compensation insurance carrier&policy no. are:
CL LO Carrier Policy No. 1•:STIMi"'fi D COST Ula I(`O NS•1!RUC710N 0.00
Z (This section need not be completed if the permit valuation is for$100.00 or less). PJ.RM I T 14%SUMMARY
00 N O (1 sf-certify that in the performance of the work for which this permit is issued, 171-AJO1,ITION FRF 101400(Y4.'_;-OW iN!
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: Q!r Applicant �� /`,✓/ I i
-� �•
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 'I Tr)TA 1,CONSTRUCTION 010 P1.t1N CHECK i IS 0'3
&hold harmless the City of Indian Wells,its officers,agents and employees. D A
aL S'S PRF-PAJU FEES $000
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 At, PERMIT FELSI DI'JE NOW S45-00
permit,or cessation of work for 180 days will subject permit to cancellation. FEB 0 9 1996
1 certify that I have read this application and state that the above information is JU
correct. I agree to comply with all City, and State laws relating to the building 113Y
construction,and hereby authorize representatives of this City to enter upon the �'""' I IIIIIII I III III III III) 51
• above-mentioned property for inspection purposes. '-""�
IE
•Slgnudlre (OWnef/Agent)/.,/�! Date RECEIPT DATE - BY D A INSPECTOR
V
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 Wali 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 I I 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
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)