9510-023 (PLBG)f2, % LICENSED CONTRACTOR DECLARATION
N CO I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W 4 Section 7000) of Division 3 of the Business and Professionals Code, and my
� :)Lo License is in fuQ_.forr4Sand effect.
r- WLicense # Lic. Class Exp. Date
Z^ Date X Iti I i. r Signatureof Contractor fes 4 04 'r•
r0�
co F- OWNER -BUILDER DECLARATION
J IU 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 B&P.C, for this reason
�
Date Signature of Owner
N
Orn
U WORKER'S COMPENSATION DECLARATION
CL Q 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'
r H O IM 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
Q U permit is issued. My workers' compensation insurance carrier & policy no. are:
rn H Carrier Policy No.
qT z (This section need not be completed if the permit valuation is for $100.00 or less).
00 N 5() 1 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
workers' compensation laws of California, and agree that if I should -become
subject to the workers' compensation provisions of Section 3700 of the Labor
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. 1 agree to comply with all City, and State laws relating to the building
construction, and hereby autho��rll��rrepresentatives of this City to enter upon the
• above-mentioned property fo ,if"`nsppection purposes.
.signature (Owner/Agent) t�-fi•,,_ Data
ALCM
BUILDING PERMIT
PERMITsy��1i�l2,
DATE 11tH *9.-
VALUATION
LOT TRACT
. nn-,
JOB SITE ADDRESS SI-�1Zs ELYI~�..E�.I�ISI�)IIii�S
APN 77333.028
OWNER
CONTRACTOR
NilM1`11L, INC
LINDA SEEMS
P Y BOX 1155
52.925 AVE. 13MIUDAS
LA QIIIN'I'A CA 92253
LA QUINTA CA 92253
564-4104
DESIGNERIENGINEER
USE OF PERMIT
tiLWER CUNNI?CC
FEE DESCRIPTION
FEES
ESTIMATED COST OF CONS 4'RUCTION
t't~;ltMl f' ih't*,l; SiiNlMAitY
O
00.0
ey .19/9S
SUL IY!TAJ, CON3PR4 MION AND PLAN CHECK
LESS PRETAID FENS
f
$3000
$000
'I'clTAL PFRMI'F IVERS DUE NOW
S,NI.liO
TUTAL I'ROlr(f I'VIUMIT FEES
30.01111
RECEIPT
DATE
BY
DA Y A
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 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
Appliances
6
Final
Final /6
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
COACH€LLA VALLk4 Wi itl3 bl6tFitCT
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ReCelved Prbrri: �- �� bdld'
Address:
AccounlNo. ' Lol(s) *` Tract-,
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p. ❑ Tutu ON Charge
❑ Uncollected AccO nI - Neme `
❑ lnepectlon Pea - Tract - i
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❑ Plan Check Pees WAFT I biWai - c
• ❑ Bond Payment - A.b. --bond
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❑'.Customer beposli
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Rdmarks:.
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SANCO - lex
PUMPING SERVICE a �` ... -2502•Morongo Trail
Palm Springs, CA 92264
(619)327-8859 . NQ 9643
SO D TO
D
TERMS
unippup
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STREET .
NO.
STREET - NO.
2-
92
i
CITY
STATE ZIP
CITY STATE # ZIP
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�U�STO�M�BR`O DER
SAS SMAN
TERMS
F.O.B.
DATE
27'o;oa .
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PAYMENT DUE UPON RECEIPT
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