9512-003 (RPL)c!1 '"! - LICENSED CONTRACTOR DECLARATION 11
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 Q License is in full force and effect. 556236 C53 2/213/97
r W License # Lic. Class Exp. Date
r- Z 4,Date Signatureof Contractor
F- 0) OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
0- following reason:
(A () 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
co Date SignatureofOwner
N
O0 rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
FQ-O cc compensation, as provided for by Section 3700 of the Labor Code, for the
K W u- performance of the work for which this permit is issued.
J J ( ) I 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 U permit is issued. My workers' compensation insurance carrier & policy no. are:
LZCarrier ,•rte r� ETZU-, Policy No. t�t.�7xn
_ (This section need not be completed if the permit valuation is for $100.00 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 to the workers' compensation provisions of Section 3700 of the Labor
e 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. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property.forin`spection purposes.
Signature (Owner/Agent) Date f ? • ci
Acr
BUILDING PERMIT
PERMIT.s�1�4w
DATE IV VY
VALUATION 3a a uc LOT TRACT
JOB SITE ADDRESS 454WO B E17E
APN
OWNER
CONTRACTOR
SUNRISE. POOLS
CHARLES HOWN
44028 ELICHCYRN'TR.
siviVIE
PALM DESERT CA 92260
LA QUINTA CA 92253
(019)340-5521 CBL# 1.504
DESIGNERIENGINEER
USE OF PERMITJ OL AND/OR SPA
POOL AND SPA
FEE DESCRIPTION
FEES
POOL AM;OR S1PA 12,000.00 LS
EST COST OF CONST.1dC)i.~'D'1ON
12,000.00
PERMIT FEE SUMMARY
PLAN CHECK 7'f3 101.000-439••3111 $87.75
C(3NSTl2UCTIO14F'EE 101-000-418-000 $135.00
NIF;CRANIC AL FEE -- POOL 101-000-421-0130 $24.00
H IE CTRICAL F.f, -- POOL 101-000-420-000 $-45.00
Pt I J. MSTNQ FEE -- POOL 101-000.419-000 $0',7.00
SUIT -TOTAL CONS'[ €ZUCTION AND .PLAN CHECK
$318.75
LESS .PRE -PAID FEES
$0.00
OTAL FEE + DL11+.1�iU1
PERMIT '
D -
W118.7fi
DEC 01 i 1995 '
B
R EIPT
DATE
BY
DA D
INSPECTOR
1�
1111M
INSPECTION RECORD
I ,OPERATION
I DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
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
POOLS - SPAS /
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
I
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final 1-7-7
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
t
Gas Tist
Appliances
T
Final L44�WY40,-Zl
COMMENTS:
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)