9510-090 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
C,4
W Section 7000) of. Division 3 of the Business Professionals Code, and my
Q `License is in full force and effect. t1 1 I3 6/30196
r� W /icense # :5 , J (P-70 Lic. Class Date
Z Date //`;Z "�/,SignatureofContractorrrf,�,
cD 0 0) OWNER -BUILDER DECLARATION
JIU I hereby affirm that I am exempt from the Contractor's License Law for the
d following reason:
I.– fn ( ) 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
U0 Date SignatureofOwner-
cm
LO rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
��O 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
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
OU permit is issued. My workers' compensation insurance carrier & policy no. are:
a rn Carrier GCrI1 ENE EJkG .E Policy No. PWC27:207700
`t Z (This section need not be completed if the permit valuation is for $100.00 or less).
r- a() I certify that in the performance of the work for which this permit is issued,
C7 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.l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those Prov. s 0AS,:,,.,� - µ
ate: d';G % 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, intarest 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.
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t
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 p,•urposes4ig�re (Owner/Agent) - > moi' `:.x .,�- Dams �2 '%V
ALC "BUILDING
`.
PERMIT
PERMIT 51 0 ,
DATE tfrncr�
VALUATION �- +rs: vc .Y7Yt
LOT 1'
TRACT <<'
JOB SITE ADDRESS 5140A•���
APN-061—
OWNER
CONTRACTOR
SUNROSE CORP
SUINIROSE CORP
721350 SONTE "A 111i3
728550 SOMEKA RD.
PALM DES RR.'t CA M1160
PAJIM DESElu1 CA 92260
(6:9046-2840 CBL# 11.37
DESIGNER/ENGINEER
USE OF PERMIT)INQL-ldI � X L L'..,i.iN"
Yonnit Niue -u 1I.ot lnchute block" N albs or pool
FEE DESCRIPTION'
FEES
TRACT CONS`i'RUCTIGN 1, 5911.00 SF
GA {AGE/C.A.R-PORT 5".18,(h) S
&:S'iR.I:iAIf3`IED Ci, &F OF WNS°b'':ItUCTION
9 ,9113.4311
PERMITFEE SU MAIA11 Y
M. DEPOSIT -$250,00
I''LA*: CRECKIF EC 01-000-439-318 $52SA3
CONSIVLE CTIONFEE 10.1-000-418-000 $62.6.00
MECHANICAL F EL 141-000.4214 0i} S60,00
llXC'I'R;CM. FEE 10.1-.000-420.000 $1.29.f35
Pi'-IXIBIXG FEL 10.1-000-419=000 6133.50
STO114 i MtYI'.1M FEE - RESID I00 -000 -211 -OW 59,69
GRADING Ft'"E 1014+000-423-000 $20.00
TW!RAS'i'i2.ucnjIx. risk, 225 -WO -443-342 $2180132
PRECISE PLA 1\ 101-000-4411-345 $25.00
SUB -TOTAL CONS°ff UCTi:OiN AND PLAN CHECK
$3,712.79 .
LESS M&PAID FEES
-$1_%9.00
T'O AIa PERMIT `'dI EFS i1I1E NOXV
$3,462.79
TOTAL. I'IZWE T PER'Niff FEES
3,712.79
,4
RECEIPT
DATE
(l�'
��y
INSPECTOR
INSPECTION
RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS '
Set Backs
Underground Ducts
Forms & Footings 7
Ducts
Slab Grade
Return Air
Steel AA
Combustion Air
Roof Deck p
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
BLOCICMiALL APPROV LS
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.Firilsh Plaster
Sewer Lateral
Pool Cover
Sewer Connection 1176,11-
Encapsulation
Gas Piping
Gas Test
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 G
Utility Notice (Perm)
COMMENTS:
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