RPL (9603-015)51780 Avenida Madero
9603-015
LICENSED CONTRACTOR DECLARATION
I hereby affirK, thgt I ar:licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professio s Code, and my
License is in full force and effect. 63498 7 1131018,,. -
Licen # Lia Clas Exp. Date
Date SignatureofContra'c`tor✓1 , 0 !1
OWNER -BUILDER DECLARATIOIN./'t •111/ Gi
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).
( ) 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
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 consent 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 c,:i , ,_ r rt Policy No. e, , c; ,
(This section need not be completed if the permit valuation is for $100.00 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`alaws of California, and agree all if I should become
subject to the workers', compensation%provisions of ection 3700 of the Labor
Code -I all forth comply with those provision . r'
Date '" r Applicant' /` % `A
/GV^
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
& 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.
1 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 autho ize representatives of this City to enter upon the
above-mentioned propertyfs Inspection urposes. -'
Signature (Owner/A9er>i)+`f / / DaEe 7-_
✓ -7r-
ALCM
BUILDING PERMIT
FERMIT96d.
DATE ; 596
VALUATION gl,® t0ecfit
LOT
TRACT
JOB qU ADDRESS
1 5;.-790 A.VI!+INIDA16 iAil . ",:t 0
APN
773-154-002
OWNER
CONTRACTOR
e
twO c cL cOr rs'rrcLrcz faz
LSEQL1 1: MCO. OWN -L'1,
6AVENII A " IOr3T' ,ril°;.R
P.O. BOX 3S5
LA. -)UINTA CA 92253
"LAQUil 'A: CA 92253
(619)5"4604 Ci t.# 2261
f09)564-4004
DESIGNERIENGINEER
USE OFPERWTIOC)L A114r)JC)R SPA
1.1001,, ANY PA.
FEE DESCRIPTION
FEES
POOL MIYOR SPR. .9,000.00 LS
11MATED C0 i' OF CONSTRUCTION
F' I.itIV 1 ' 1;'E.E Si31Vi'MARV
PL ATS,'` CHECK Ft%i4 101-000439-318 $70.20
C'Oris°t'1 UCTIONFFE 101 -000 -418 -MO $xos.00
_U
KECrHANICAL FEE— POOL 101-000-421-000 SZ1100
LO
ELFC'I'•R.IC;AL P'F,E -- POOL 101-000-420.000 t $45.00
CT)
Pr UMST'NIG rJ:T._:khool. 101-000-419-0N) $27.00
7 GD
O
Q 1,Z
d
SUB-7far,AL CONs'r1Cummi\r AND niw atecK
$274.20
..LESS PIM -PAID FEES
$0.00
'H't3TAL PERM T ;FEM DUE NOW
5276.20
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
St Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Stmt
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
;//6
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
D G
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
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
Final
Utility Notice (Perm)
COMMENTS:
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. A DATE
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