9504-126 (SFD)U) fLICENSED CONTRACTOR DECLARATION
��� I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r 12 .y_ Section 7000) of Division 3 of the Business and Professionals Code, and my
o CY U-) ' License is in full force and effect.
C 410.991 R 7/31 i96
r` W n License # Lic. Class Date ; w
Z n Date 1Z 1\t)\q Signature of Contractor \ ) 1e.3J
J
F- o) OWNER -BUILDER DECLARATION
J U - I hereby affirm that I am exempt from the Contractor's License Law for the
w W following reason:
~ U) () 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
—
00 Date Signature of Owner
to
N
O rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
C)2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
C)
cc O compensation, as provided for by Section 3700 of the Labor Code, for the
X IL 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
co Q U Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
a LO Carrier.,., Policy No.
Z (This section need not a completed if the permit valuation is for $1'00.00 or less).
r- a() I certify that in the performance of the work for which this permit is issued,
O 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 t the workers' compelasation provisions of Section 3700.,of the Labor
I � — .
Code, I,s � forthwith comply wii o pr��Yislons.
Date: `� �' U Applicant ��UC
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 com • with all City, and State laws relating to the building
construction, and herebytho ize�representatives of this City to enter upon the
•` above-mentioned property f i spec on p pose
Signature (Owner/Agent) Daae�
ALC 'BUILDING
PERMITAwno
PERMIT•
DATE 5l 9196
VALUATION S92,543.JC
LOT9
TRACT 222
JOB SITE ADDRESS
APN
3-405 AVEN- A iARFUNZA 7
774-07S-021
OWNER
CONTRACTOR
DAVID ROSS IMILLE1t
PACIFIC TI'ADES
P.O. BOX 722
P.O. "BOX 722
LAQUINI'A CA. 922.43
LA !'UIN'I'A t''A 42'•i3
DESIGNR/ENGINfE�R� (V)A )<15S
USE OF PERMIT
PERMIT OOES NOT INCLUDES HI.C.CK, OR POOL
FEE DESCRIPTION
FEES
't RA.CT CONS'i4.tUs.''i,`(ON I.5'i5.00 SI.
K -W, t PATIC) 36,00 S1
GiARAGWA18POR'1' '500.00 SF
E S"I IW` ED COST Or, C':O Nl3'MUC 1710N
9.2,,54130
PERMIT FEIP, SUMMARY
CONSTRUC1ON FfW, 101-000418-000 01-q00418.n00 p ±
PLAN CHECK' brr6 101-000-439-318 $515.23
FEE DEPOSIT 4230.00
� —
iVlE,A'7.I1FVN1CAL FF9 101 -000.421 -ON $53.50
W \
ELBM RICAL FE[8 1.01-(x 0420-CI00 $126.53
�
Cn
M UNISING F,}`s I01 -L100 -40 -ow $142.00
Q rn
ST011G>vKIN014 Fa - RESID 1014100-241-M $9.2:5
c,
MADING FEE 101.-000-423,000 $20.00
INFIIAS 17RUCTURF, FF:F 225-000-443-342 $2471.45
Q ( >_
PRECISE PLAN' !01-00-4 41-345 $25.00
SUB -'TOTAL ("_ONSI RUC1'IC)N AND PLAN CAECA
$3,570.945
Uss Pit.C-I'AM FUS
42150.('1)
TOM, I'EIttA41T FELS DUE NOW
$3,320.96
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
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