9608-038 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm.that I am licensed Under provisions of Chapter 9 (commencing with
Secoon 7000) -of Division 3 of the Business and Professionals Code, and my
License Is in full force and effect. 164,1
License # Lic. Class Exp. D
Date jZ)_ SignatureofContractor.,41
4_oq - gz,,�_ zv
C� , 7 -r -
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 Ae structure Is not Intended or offered for
sale (See. 7044, Business & Professionals Code).
( ) 1. 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 I 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 lnsurance,,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 1,1 rK,) . Policy No. I I R17%r,
(This section need not be completed if the permit valuation Is for $100.00 or lose).
( ) 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
Pode, I phall forthwith comply withoose proyiskmq. li 7
Warning: Failureto secure Workers'Compensartion 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 applicertion 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 daye from date of issuance of such
permit, or cessation of work for ISO days will subject permit to cancellation.
I certify that I have read this application and side that the above information Is
correct. I agree to comply with all City, and Side laws relating to the building
construction, and hereby author
, . lize representatives of this to enter upon the
above-mentioned property fo(Inspectict"rPAGS
I
Almnature (Ownerl,
ALC
BUILDING PERMIT-
PERM,46in-ou
EXTE
VALUATION ".7.5MINd LOT
TRACT
JOB SITE ADDRESS 55-' 525 CHERRV H1 US
AM 769-624"24)
OWNER
CONTRACTOR
I 1A MIL: FON N1XS,01'I R Y
1. t.,V L". AN 4;� I'& .111M 4 1 1, k". A.,
er,X I I
,53525 C14k-.'KRY RLS
LA. QUNTA CA �)225�
LA 01JINTA CA 92753
C
(6h�)34_5409 1431
DESIGNEWENGINEER
USEOFPERWr1L-'r4r4J?u'11,. BUILDING
190 1—F, 4_)FO H1014 OikKI)LN HLOCK WALL. 33 1/4' L.F. UF THI(JR PLAKFER WALL.
FEE DESCRIPTION
FEES
6 Vi. Wiki,L 190AW LIF
EST MATED COST OV COINSTRUC71 ON
4,750.00
111,14MIT FEE SUMMARY
(27ONSTRUCT(ON FEE 101 -NO -418-0(K) $72.00
SUP -TOTAL CONITPRUC.1710N A -MD PLAN CHECK
$72.010
LESS PRR-PAID FEES
$0.00
91TAL PERMIT FEM DUE: -NOW
$7Z.00
JAN1 0 1996
BY
FECEIPT
!'
IBY
DATF'RNALED
PECTOR .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set 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
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond B m
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltne Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Ublity Notice (Perm)
COMMENTS: