9601-0119 (BMCH)54521 Avenida Alvarado
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 SignatureofContractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the'
following reason:
( ) I, 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).
( ) 1, 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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of corisent 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).
( ) 1 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
Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Cornpensation coverage is unlawful and shall
subject an employer to criminal pen ties and civil fines . up to $100,000, in
addition to the cost of compensation, d ages 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 worlys 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
aboh n ;lt'toned property for inspection purposes.
Signature (Owner/Agent) -.. Date : !
A`°"
BUILDING PERMIT , d .
PERMIT a_ .1
DATE l(22196
VALUATION $ .'4`{1(10.t1ft
LOT TRACT
JOB SITE ADDRESS
54-521 AVE .ALVA.RADO
APN
,
OWNER
DOLORES GItANILLO
54-521 ALVA&IWO
LAQUINTA CA 2253
343-0431 •
CONTRACTOR
OWNER/BUILDER
,
CPtl,3f
DESIGNER/ENGINEER
USE OF PERMIUCN%RA.L BUILDING
RE-I.A1.'f..WE-DRYWAL.L/NEW A/C INSTALLATION/SEWER CONNizr SEPTIC ABANDON
FEE DESCRIPTION •
FEES
VALUA2'ICN - S.00O.001.8
ESTIMATED COST OF CONS•1'1:13 :``1 ON
PERMIT :FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000
a.
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
. LESS PRE-t'AID
TOTAL PERMIT FEES I)'t. E'NOW
'
$?2.00
a
.1
FEES
• . S,004.116
=-
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-I
CO
CO
I
QC
?2.00
. ;50.00
S72.00
IIIIIIIIVIIIIIIVIIIIIII
63
f IE
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
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
1
/ 9(
��
•
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
-
• 4 - 2
-" Gas Piping
PLUMBING; APPROVALS
A
; ,a,
c .Gas Test
;-Electric Final
.Waste Lines
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
.e
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer
/J /f/fb
ver
Pool poula
Sewer ConnectionLateral
• �jj
• ;
Encapsulation
Gas Piping
,.
Gas Test
-4 ,,
•
Appliances
a:
ifiVidA/
earA1
1,�'
'
Final
:
/
COMMENTS:
_
=
r
_
•
" ;
-
1
-
,i
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
_
Underground Conduit
Z.
Rough Wiring
-_
LowVoltage Wiring
`_
Fixtures-
-
Main Service
Sub Panels
:Exterior Receptacles
,G.F.I.
Smoke Detectors -
Temp. Use of Power
-.
Final
Utility Notice (Perm)
5775:2/Buifdi ig
Address
Mailing
•11-NAddress /91/v- c-/c7C-
4 :91.Q"
P.O. BOX 1504
c, UINTA, CALIFORNIA 92253
CALLE ESTADO
Cit
Contractor
T_Viov/
"WV B / of e
Address
BUILDING: TYPE CONST.
A.P. Number
11111111 IIIII SII NV 64
IE '
APPLICATION ONLY
OCC. GRP.
Legal Description i x
Project Descr• ti , . MFAMlir q !
Irl
NA
i
City
Zip
Tel.
State Lic.
& Classif.
City
Lic. #
Arch., Engr.,
Designer
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New 0
Add 0 Alter 0
Repair 0
Demolition 0
Address
Tel.
City
Zip
State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
elfect.
SIGNATURE DATE
OWNER•BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter. improve. demolish. or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code. Or that. he is exempt therefrom. and the basis
for the alleged exemption. Any violation 'o! Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).
I-: I, 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I 1 I, as owner of the property, am exclusively contracting with licensed contractors to con.
struct the project. (Sec. 7044. Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) .
it I am exempt under Sec B & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
Policy No. Company
fi Copy is filed with the city. 0 Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100) valuation
or less.)
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit Shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097. Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that 1 have read this application and state that the above information Is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives .01 this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
Estimated Valuation
i
041 6:ka
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE' BY.
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by. Date Permit
Validated by:
Validation: