PLBG (9511-007)54585 Avenida Martinez
9511-007
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. 265214 C42 1 V111,05
License,#L f Lic. Class Exp. Dated
D /1 ; !; :' Signatureof Contractor J , R' e j
Y
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 intendedlor 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 STATI; I UND Policy No. 699.4-1194(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 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'.
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 vol i
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to canoe) on. V
I certify that I have read this application and state that the above infor , a,tion it
correct. I agree to comply with all City, and State laws relating to t14- -dilding
construction, and hereby authorize representatives of this City to enter po thh
above-mentioned property,ffor,r,insp/ection purposes.
Signature (Owner/Agent) /-., &ee., to ..6—%.. . Dads
i
ALC0
BUILDING PERMIT
PERMIT,55,11,'I)0,7
DATE S /
VALUATION '"Mm LOT
TRACT
JOB SITE ADDRESS . ✓1 J .✓
AIN 7 742,45012,
OWNER
CONTRACTOR
R -i f',WSP OL, SE,R. 1CF, MC
0- E1W.D SRML'EX L,A.K8
168191"Fr1'LI; it m,ONC C) ;t.f).
5,4595 AVENIDA M.tl, I?,qFZ
I?ES.ER:r fiat SPKING; CA 92740
LA QURNTI-A C'•A. 9=2253
6193296Et 75 C81,# 396
/143613839
DESIGNER/ENGINEER
USE OF PERMItLUMBiNU
FEE DESCRIPTION
FEES
CONTR,AM AMOLM 1,850.00 LS
ES't UMATE, D COST Or, CONSTRUCT 104-4
JX50.00
PE11:KtYY VE;:E SUMMARY
S 1340TAL C01\19MUC" ION AND PLAN CHECK
$30.00
1.1;SS PRE -PAID FE'E'S
$0.00
I f, a fiat;` t pyW
01 f f PERMIT
O •Y ,/•i'.FIL Y .b 1SS7J1 l. .Csl:n7 DUE 9:i Sw V 7
1 0
. , J(I.fiV
'OTMAL PR"TECT Pirltirvfff FEES
0.60
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR 7771
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
et 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 APPROVALS
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 j/ 3 js'
Pool Cover
Sewer Connection / 3
Encapsulation
Gas Piping
Gas Test "
Appliances
Final
COMMENTS:
Final Q
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)
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COACHELLA VALLEY WATER DISTRICT~
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CASH RECEIPT DETAIL
/
Date
Received From: :-)—P
Address:
Address:/ ,
Lot(s)
ract
Tract—
Account No. ry
G.A. Code
Service Address
❑ Meter(s)
i ❑ Service(s)
• ❑ Backilow(s)
❑ House Lateral(s)
t
❑ DetectorCheck(s)
I
j
' ❑ MeterBurcherge
Charge
nitalion Capacity
❑ WS.B.F.C.
❑ Temporary Construction Meter
L
❑ Tum on Charge
❑ Uncollected Account - Name
'
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I sewer -
—
1 Tract -
❑ Bond Payment - A.D. - Bond
-
Assmt.
I ❑ Customer Deposit
❑ Other
TOTAL
S
Remarks:
k
i
Water Service
❑Copy to:
/
Cash -
heck
Cashier L
CVWD-438111189
on
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der
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1
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
N2 10106
SOLD' TO%
SHIPPED TO
STREET
p � STATE
STREET NO.
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CITY STATE J ZIP
CITY STATE zip
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CUSTOMER ORDER ! SALESMAN
TERMS
DATE
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;
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PAYMENT DUE UPON RECEIPT