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9602-053 (RPL)P LICENSED CONTRACTOR DECLARATION N U) 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 Cy co License isyin full foice and effect. 6itil7$ ,53 101 1196 N W License Lic. Class Exp (Date rZ n Date l "r('rf Signatureof Contractor i A v1,...ti.�•^"'"� 0 0) OWNER -BUILDER DECLARATION .J W I hereby affirm that I a ' m exempt from the Contractor's License Law for the 0_ 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 C0 Date Signature of Owner LON Orn U WORKER'S COMPENSATION DECLARATION a Q I hereby affirm under penalty of perjury one of the following declarations: g Z () I have and will maintain a certificate of consent to self -insure for workers' n p compensation, as provided for by Section 3700 of the Labor Code, for the KW LL. perform ce of the work for which this permit is issued. ] J J ( have and will maintain workers' compensation insurance, as required by n Q U Section 3700 of the Labor Code, for the performance of the work for which this j.0 permit is issued.''` y workers' compensation insurance carrier & policy no. are: LLOCarrier CAL COW Policy No. W955119537 ? (This section need not be completed if the permit valuation is for $100.00 or less). CO r` Z)() 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 to the workers' compensatio provisions of Section 3700/of the Labor Code, I shall, forthwith comply with ie provsions Date: L. ,'',�. ,er -- I I'Applicant to i 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 comply with aJ�6ty,�6d State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspectiorn;purposes: Signature (Owner/Agent) L//� /'�+rll µl/% aP Dats� ALCM . -BUILDING PERMIT PERMITi�1.3 DATE Xr VALUATION J, LOT TRACT JOB SITE ADDRESS 79 335BRIARWO.D APN OWNER CONTRACTOR CAL1FORM!A. POOLS & SPAS SP.A.RK.S CONti I' 41910 E3Q.A.12.DWALK AA2 19-335 BRLARWTIOD �" " PALM DESEV CA. 92260 LA QUIWA CA. _ 92253 (619)340-9000 CBL,t# 35.5 .. DESIGNER/ENGINEER USE OF PERMIT-10Vtt .i 0!01- SPA POOL ct; SPA-OM.Y FEE DESCRIPTION FEES POOL AND/OR SQA i 1,000,W LS F.a1'TVIVI TED COST OF CGINSTRDcrm PERMIT FEE SUMMARY 111000.0€1 PLAIT CHECK T•ElF, 1,01-fM. 4 s9-3111 �R1 90 COINSTP,UCPTON FEE 10I.000-418-000 $126.00 h4ECHA fC:AL F�W- --'BOOL .101-000-421-000 $24.00 r11EC:'1'F (C L FW1-- PoaL 1,01-300-410-000 $45,00 Ca -^ 41.,1.911rT1dING FEE --POOL 101-000-419-000 $27.09 S`UI3-7'©':1',U CONMUCTION AND PIAN CHECK LESS PR.E.�PAID PEES `DOTAL ;f'I1:Ti.MIT FEES DUE :NOW - 1 5 C� � ria / O all m W LL_ $30.90 $0.00 1W03.90 RECEIPT DATE By DATE FINALED INSPECTOR 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 r Footings Main Drain Bond Beam 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 O.K for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation c ... G . 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: