9512-004 (RPL)LICENSED CONTRACTOR DECLARATION
N 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 a Lo License is in full force and effect. 359105 .ACID 5/3.1/95
I- Wn License # Lic. Class ExP. Date
r- Cl Date Signatureof Contractor
c'o P OWNER -BUILDER DECLARATION
J WCD
1 hereby affirm that I am exempt from the Contractor's License Law for the
CL following reason:
Z( ) 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, 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 S&P.C. for this reason
C! -Date Signature of Owner
*- -
Drn�
WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
o g Z () I have and will maintain a certificate of consent to self -insure for workers'
Lo FQ- 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 --I ( ) I have and will maintain workers' compensation insurance, as required by
00 Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U permit is issued. My workers' compensation insurance carrier & policy no. are:
LO
a rn FQ- Carrier NIA Policy No. VA
' Z (This section need not be completed if the permit valuation is for $100.00 or less).
r- Cy() I certify that in the performance of the work for which this permit is issued,
Cy 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�Sebtion 3700 of the Labor
Code, I shall forthwith comply with those provision
N 4Date: 4t /-4/ pplicant�'! . `
Warning: Failure to secure'orkers' 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.
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 aonze representatives of this City to enter upon the
above-mentioned property 6/r inspectionpurposes. +f
"Signature (Owner/AgDate'f�✓
ALC
BUILDING
PERMIT
PERMIT?,.,;,
DATE 11V 11Y.1
VALUATION 1I y,1 9ir.tNl°
LOT
TRACT
JOB SITE ADDRESS 77_215 AVU. ARTFGA
APN
OWNER
CONTRACTOR v
T14FRI13AU CONMUC ON
C'RE-1.1110 EE .110AIMIS
4741 C.E.1'��.L,;�1
798ii COUNMY CLUB DRIVE
PALM SPRJNGS CA 92264
BERMUDADUNE! CA 92201
(619)"1""18-3939 C33L# 250
(619)345.6725
DESIGNERIENGINEER
USE OF PERNVOO.i, AN Dj'QR SPA
P(X.?L ANO SPA -
- - - FEE DESCRIPTION-
-- FEES
POOL A th IOR SIiA 15,000.00 LS
I
l
EA'11W%.TED COS C OF CONSTRUCTION
15,000.00
PERMIT FEE SUMMARY
PLAN CHECK FEE 1()1.-(100-439-3113 $105.30
•:
CONST11'UCTION .f± 6'E 101-000-4.18-000 S tismoo
MWILANICAL FEE -- POOL 101-000-421-000 $24.00
ELPL rRICAL FER -- POOL 101-000-420-M 543.-6
PI.I)NM1NG FEE- -- PCXX 101-000-419-000 $27.00
Cn
V
L.ILi
SUB -TOTAL CONST UCTfON ."D PLAN CHECK
D63.30
USS PRE -PAD FOES
$0.00
TOTAL PERMIT 1+ E..S DUE NOW
$363.30
RECEIPT
DATE
BY
DIE•
INSPECTOR
ONAILED
INSPECTION RECORD
OPERATION
DATE
I 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 zg-
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric /Z
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test r
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 t5 -104P /
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 -
Utility Notice (Perm)
COMMENTS:
owL
E -
R
6 tu"- BE SELF-CLOSI NG
AND SELF -LATCHING,
0 L
MV
IT
iJt
vc-
, cl
JE C T TPO
iq 8 pp
IND ALL APPUFA
DA TE
+ 50 50
Pool
Ll 7�
FI 0
I
r•1AR- 7-yc. T Hu 7 c Cv S E W E R r•1ATERji ALs
t
CALIFORNIA PORTLAND CEMENT COMPANY
2023 E, FINANCIAL WAY, GLENOORA, CA 91741 / 7E- 18181 852-6200
March 28, 1995
Beaumont Concrete, Inc.
P. 0. Box 216
Beaumont, California 92223
I,I
Attention: Ski I
r ,
} 9 -
Rl:• CERTIR TIO�i '
.1 I
Gentlemen: {
This is to certify that MOJAVE Portland Cemont, Type II/V, supplied lo'�yait has bcen MMILi�'actUred
in accordance with and meets the standard req' tiirements of the Current ,�, 9TM C 150 for Type HN,
Low Alkali•
Very truly yours,
l
}1
Ill - s R. RI, e t
Manager of Traffic & Mark -min
STATE of CALIFORMA)
R _ v_1
County of Los Angeles
On this the --Ht— day of a ch in the year_99 bcforc me, Yojinda Notary Public in and for said
State, personally appeared James R._Ri_sse , personally Known to me to be the person w-bose name is subscnibed to
the within instrument and acbowledgcd to me that he mcuted the sante in Lis authorized capacity, and that by ,his
signature on the instrument die person or the entity upon be Wlf of which the person acted, executed the
instrument.
WITNESS my hand and official seal.
dint OR A
y MANDA DW No ary Public in and for said• e
w.
r ..
ail r` Iril
il �..,.... . SIR ro.) F
ISOMETRIC
r -e ..r
r , ""r r. ME
PLAN VIEW -LID
SECI-ION-LID
COACHELLA VALLEY SEWER
'