9510-087 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
o = M ,J
License is in full force and effect. r- .,-
� O � �te'I;U.7U B 66sGivo
I". W License # Lic. Class Exp. Date
n Z Date — /..: SignatureofContractor
(T0 P OWNER -BUILDER DECLARATION
LL
UJ W 1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
~ (n ( ) I, as owner of the property, or my employees with wages as their sole
Z 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
co Date Signature of Owner
LON
Orn WORKER'S COMPENSATION DECLARATION
L)
Q I hereby affirm under penalty of perjury one of the following declarations:
C) g Z ( ) I have,and will maintain a certificate of consent to self -insure for workers'
�O cc compensation, as provided for'by Section 3700 of the Labor Code, for the
X W LL. performance of the work for which this permit is issued.
O J J ( ) I have and will maintain workers' compensation insurance, as required by
C0 Q U Section 3700 of the Labor Code, for the performance of the work for which this
p Q permit is,16sued. My workers' compensation insurance carrier & policy no. are:
CL LO 1 Carrier r..- ., Policy No. s .i��+�•,,,ia^
Z (This section neeiino'be completed if the permit valuation is for $100.00 or less).
co :D() I certify that in the performance of the work for which this permit is issued,
d I shall not employ any person in any manner so as to become subject to the
g workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
®6 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 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
• above-mentioned property for inspection purposes
:
1 Signature (Owner/Agent) Date % 1 7-5—
ALCM
BUILDING PERMIT
PERMIT���41 !3'J
DATE J, 1J 9jSf
VALUATION 4 'f)x>flEi
LOT ]_� TRACT '73
JOB SITE ADDRESS
51-676 AVE, CAMI''�i�
APN
M-06.1-665
OWNER
CONTRACTOR a
SUNR.OSE CORPORATION
SUN OSSF, CORP
`7^-9850 SOt.IERA RU.
728:0 SOM.ERik "RD
PiXLA,I DESERT CA 92260
PALM DESERT CA 9226()
0;BLO 1,1.37
(019)W -2N., 40
DESIGNER/ENGINEER
USE OF PERMITi1i�4iJX FAMILY DWELLING
I ennit does not, iowlade block %vWls or Pool.
FEE DESCRIPTION
FEES
TRACT CONSTRUC:rION 1,55 ,00 SF
UARAQFJC"i1RP0KT 41.0.4A) SIP'
E'ST.I ir�.,l~% CON T OF CONS s"RI i10N
92,201.66
E'ERMi'l'S1,T4<'t1tIARY
1'.1.AN ("111;M } , 101-000439-3113 $51.4.58
_
I WSTIRUMON FEF 101-000-415-000 $308.c1Q
r}r1 CHA141C'AL FEE 101-000-421-000 $60.04
lr.LPNi- MWCA>;.:I 1,E 101-000420-000 $ M5.95
P'i:LThi -i111NO I % 101-000-419-000 $133.50
STG'11TG MOTIOAT FEE - kESiD 100-M-241-000. - $9.22
ORA.OR40 FE17, 101-000-423.000
f.N RASTRUC- lUKlr: F.r., 225-000443-342 $2,074. ?
A -
P'It£G1SU PLAN 101.-000-441-345
FEE DU10S!.T
NO V 1 3 1995
ZV
:1
SUB&TOTAL C.ONMUC;110N AND PLAN CHECK
$3,570, 77
3,570,7'7
LESS PRG -PAID FEES
42-V.00
TO�^t�'1.AL PERiY IT F"�.ESYpDUE
SNOW
�O1�:
af
i.,�L P.6R�3irtc—, . r t tr ri Fui..s!'
M
3,,570.77
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
W
t INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR •
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/
Underground Ducts
Forms & Footings
Ducts
Slab Grade/
/ f
Return Air
Steel
// J/
Combustion Air
Roof Deck
// j
Exhaust Fans
O.K. to Wrap
Q i
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 APPROVA S
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
3z
Appliances
Final
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)
COMMENTS:
1
QSIo -o�J
Building ^ _
Address
Owner
S/.i s�1 ✓'�?S Pte- b/'O �'llG R > e
P.O. BOX 1504 APPLICATION ONLY
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
mailing
Address 7,x
City / Tel.
MUM l%Zip.".11-F `1J>/,-3ff6-,zeyd
Address
7� - I
rs�c 7 / Dss,.�/��
State Lic. City
& Classif. (� ^ 5-33/570 Lic. #
Arch., Engr., 11
Designer
4 ..r
Address Tel.
CityI Zip I 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
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's 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 of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
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 ownemployees.
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 1, 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. 8 P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I 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
n Copy is filed with the city. O 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 ($100) 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, atter 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
4� 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 of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, State, Zip
BUILDING DIVISION
LDING: TYPE CONST. OCC. GRP.
P. Number
:gal Description
oject Description �7
Sq. Ft. No. No. Dw.
Size Stories Units /
New q/ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. �� C 'j
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL �� • }�
REMARKS
ZONE: BY:
Minimum Setback Distances: \
Front Setback fromeCet r) ne
Rear Setback from.Reeaf P" op. Lin'
Side Street Setba!5/X m Cen of e
Side Setbackip P(o Line \(
FINAL DATE (/ el SPECTO
Issued by: DatePer
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. @ $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SO. FT. @
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. Ca'
GAS (ROUGH)
METER LOOP
GAR. SO. FT. @
I POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SO. FT. @
GROUT
WATER HEATER
WALL SO. FT. @
FINAL INSP.
DRINKING FOUNTAIN
SO. FT. @
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP,
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL , HOOD
SIGN
WASHER(AUTQ(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
KITCHEN SINK
ABSORPTION SYSTEM. B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE,TEMIPERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
LATHING
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID @ 11A c
SEWAGE DISPOSAL
SO.FT.GAR @ 3,ec
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE TUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP,
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCG.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL