PLBG (9510-106)52150 Avenida Madero
9510-106
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.
z_
License # Li?-Adln s: ' .9 - Ef'xp. Dates 4!30!91
Dated,=fSZ J'-SignatureofContractor
OWNER -BUILDER DEC_ IAFiATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
() I, as owner of the pioperty, 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).
(.) x 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 Policy No. — —1.
(This section nee 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 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' 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's
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. f
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
E' I
above-mentioned property for inspection purposes.
/"Signature (Owner/Agent) Date
ALC '
BUILDING PERMIT
PERMITa
DATE 10/31/95VALUATION
3.i1Q9
LOT TRACT
JOB SITE ADDRESS
APN
5-2-I5€1 AVL MABER0
773-203.s11(NA
OWNER
CONTRACTOR
VALLEY PL-U'MB NCa
STAN1.13, v & S ARALEF SNIFF
40180 CL1N rO N• .
52150 Ai/LN10A MADIRO
!N010 CA 92at)1
LA QUINT.A CA 92253
(610)147.3679 f`'fYl .# 101
DESIGNEwENGINEER
<
USE OF PERm'kUM NG "
ADD A'' 42 GALLON WAXER 1EA.1'M
FEE DESCRIPTION
FEES
CONTRACT AMS}'1:7Mf y ' 300,00 .LS
PERI rf FEE SUMMARY `'
Pi;i7b B(NO FEE $24.00
SU13JMAL CONSTRULMON .AND PLAP4 CHUCK
$24.00
LESS P:REI-.PAID FEES'
$0.0
TOTAL, PERM ff,FEFSDUE Now
$24.00
1 1995 '
TOTAI, PROJECT . , t?V11T FEF_
- .ta.0a
/
RECEIPT
DATE
BY
DATE FINALED
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
3/ S dz
Final
Final=/00/Y
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)
COMMENTS: