BLDG (9511-033)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 # U6%6 l s Exp. Date R/
e
Date /' a SignatureofContractor'
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason: •
( ) 1, 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 Policy No.
(This sectio AIW&ndt=13'etcompleted if the permit valuatio 'i0o7 $150:00 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, indemni
& hold harmless the City of Indian Wells, its officers, agents and employli
2. Any permit issued as a result of this application becomes null and v"
work is not commenced within 180 days from date of issuance oft
permit, or cessation of work for 180 days will subject permit to cancellation.
r !
I certify that I have read this application and state that the above inform y'on i
correct. I agree to comply with all City, and State laws relating to the buildl,.g
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signadure (duvner/Agent))' ` Date //�.�
I
"""
BUILDING
PERMIT
PERMITi
��x •>t_�r, ax
DATE IN 7195
VALUATION s1,75f).m1
LOT TRACT
JOB SITE ADDRESS
APN
qi)_ 6 A41, ►er�k rsc
OWNER
CONTRACTOR
MIN1,17ME1..1XPA1INITIF 7 COW,
MINIS"i"tt.tiLLI-RMTED COW,
50445 dD
50445 MOUNTAIN SHADOWS RD
1A QU[NTA CA 92253
LAIaIJINTA CA 92253
onn P164
DESIGNER/ENGINEER
(60).564-1849
USE OF PERMIT
Ci1;'i rx..tkL ,i ",,L 3.tt,NG
70 AL f. at 61.frWi f ardett!>iack wail.
FEE DESCRIPTION
FEES
6 F T , WALL 70.00 LF
CONS'I;fttlr.;'i ON FES 101 -000 -418 -OW 545.00
SUB -!'MAL CONSTRUCTION AND PLAN C.HI.sCK
595.00
LESS PKP,-PUD EiE.f:S
$0.00
•A.MALPERNIff FRKSDUENOW
$45,00
199 � i
_O ! gg R Me'J PERMIT
Ep, MTN
`'
_RECEIPT
DATEBV
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
creel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam -ME,
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
t
•,• 'moi V �t: .t",'.Z e y1�fiFy..r. p-
s
CITY OF LA QUINTA
{
'
�E•o►,:� s
BUILDING & SAFETY DEPARTMENT
777-7012
-
INSPECTION REQUF6T LINE
777-7153
Ministrelli,Construction �{/0
Owner
Same F��. �70-
9
Contractor
'
9511-033 S
Permit Number
a
POST ON JOB IN CONSPICUOUS E .
INSPECTOR MUST SIGN ALL APPLICABLE SPACES.
50-285-W Shadows
JOB ADDRESS
701.f. of 6' high garden block wall
TYPE OF INSPECTION :;y_ DATE' IN SP.
FOUNDATION 8 SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING t
PRE-GUNITE'
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED•
CONCRETE SLAB
JOISTS 8 GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS 8 GAS TEST
r HEATING 8 VENT:; A/C
FIREPLACE
ROOF
BOND BEAM'•
O.K. TO WRAP
GROUT ❑ 4' ❑ 8'
FRAMING ^
INSULATION
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
I "L I'Ht rugb I LH I I
P(X)I FFNI^F A r.ATF
SEWER SEPTIC TANK
FINALS
ELECTRICAL
PLUMBING
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER.:'
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
1/95 TURN ON UTILITIES OR OCCUPY BUILDING