9511-128 (WALL) ALC AUILDING PERMIT PERMITi•+t t
� LICENSED CONTRACTOR DECLARATION _
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with DATE J 9i.G It YO VALUATION X.r K-•1 LOT TRACT
r W Section 7000) of Division 3 of the Business and Professionals Code, and 'my
C) =) co License is in full force and effect. 15651.02 .(j( ,i 1/96 JOB SITE ADDRESS 00-439r0TH t��,1H"<. APN
� Q � 76$-270-004
r- w ^ License# f-,"Lic.Class Exp.Date rt
Z ' M i� . ' g�—� f iL�✓f�'f(i� �,.<- - �y OWNER CONTRACTOR
uTfI BEAST;CjFNf'AAT,CONT.
r Z r ,Date - `� t ',_Si nk&eofC ntractor T .;r s/ I
O ;Z,uC1T�. \'A!�I�:�iRS�? 8021(y)"VII `:'
cp H 0) OWNER-BUILDER DECLARATION
J U I hereby affirm that I am exempt from the Contractor's License Law for the 80159 50TH AVT' INC) CA 92201
uifollowing reason: INDIO CA -02201 (u19j:5+4-362 0 C'I;L,# :3033
Z O I, as owner of the property, or my employees with wages as their sole (614}1'3{4;3680 DESIGNER/ENGINEER
compensation,will do the work,and the structure is not intended or offered for I I IIII II ILII III III I IIII 55
sale Sec.7044, Business&Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed USE OF PERMIT.raS.iV Gh ezl,U L.: d� r.A
IE
contractors to construct the project(Sec.7044,Business&Professionals Code).
( ) I am exempt under Section , B&P.C.for this reason 469 L.F.OF r,'.I•tv*l 0AItlJEN 11I.O 'K WALL
C11) /� g `- �i� �L ro I..1:.Chi~ 2'F1iisli r:1A "af 1�LANt'E:B.'WAF,i
Date ;2, Si nature of Owner n e7
cm
OU rn WORKER'S COMPENSATION DECLARATION FEE DESCRIPTION FEES
d Q I hereby affirm under penalty of perjury one of the following declarations:
g Z ( ) I have and will maintain a certificate of consent to self-insure for workers'
Lo H OS 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.
O J J ( ) I have and will maintain workers'compensation insurance,as required by
m J U Section 3700 of the Labor Code,for the performance of the work for which this
O U permit is issued. My workers'compensation insurance carrier&policy no. are:
Q: rn H Carrier Policy No.
It Z (This sectioJn need-,nottbe,':completed if the permit valuati6n;isJor3$100-'QDor less). LSTIMATED COST OF CON rTRUCC.EON 11,723.00
00 Q ( ) I certify that in the performance of the work for which this permit is issued, PEItM I't FEE SUNIMA1"Y
I shall not employ any person in any manner so as to become subject to the f`S3rV`�Ttttid"PtCi�l FFA 1011A I-41.940) $13�.fWi
workers' compensation taws 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 , t
for a permit subject to the conditions and restrictions set forth on his application. ;CDU 2 `7 1995
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 ,, "IEC�t
&hold harmless the City of Indian Wells, its officers,agents and employees. .�. .' 1 1'I.C0N.W,KUCF10N AND PLANC , 1+135.00
2.Any permit issued as a result of this application becomes null and void if LES; (?1{1~_1"AID:FLFS $0.00
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. TO' A-L PF-W'%IIT FRES DUE NOW SI313.00
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 TOTAL PftaJ i+.,(`.'T PERMIT w EIRS 135.00
construction,and hereby authorize representatives of this City to enter upon the
• above-mentioned property for inspection purposes. -� »...
`Signature (Owner/Agent) �W' A Datg 1/' �
"�'" ' RECEIPT DATE BY DAT l,�D q INSPECTOR
I t ; (J
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 APPROV S 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
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
r Final
Utility Notice(Perm)