9510-065 (SFD)H LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
WSection 7000) of Division 3 of the Business and Professionals Code, and my
�o d Lo License is in full force and effect. 314473 ►�.�-" 1/31/96
r- W
n License _ Lic. Class ";✓" Ex.p...:-'DR�at.e
ate SignaureofCnactor y
Z '
- :�^"'
co rn OWNER-BUILDER'DECLARATION--
,J w 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
- WORKER'S COMPENSATION DECLARATION
Q I hereby affirm under penalty of perjury one of the following declarations:
32 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
u �. cc compensation, as provided for by Section 3700 of the Labor Code, for the
X W IJ_ performance of the work for which this permit is issued.
p 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
p U permit is issued. My workers' compensation insurance carrier & policy'no. are:
HCarrier Policy No.
? z (This secttdrVh6b-"' ,6'elcompleted if the permit valuatiorViif6f,1000.00 or less).
�
C3() I certify that in the performance of the work for which this permit is issued,
C3 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 suchr
permit, or cessation of work for 180 days will subject permit to cancellation. I
�C
I certify that I have read this application and state that the above information is�
correct. I agree to comply with all City, and Statealaws relating to the building
construction, and hereby authorize representatiVes of,this City to enter upon 1114611146•1 above-mentioned property for inspection=purntpnses.� ' I
ignature (Owner/Agent) .� r..+ . - D45
ALC '_BUILDING
PERMIT
PERMIT�ai�u�
DATE T
VALUATION
LOT `Y I
TRACT '
JOB SITE ADDRESS 79-305 CAjlJIWO ;( EL ORO
APN 604.-192-025
OWNER
CONTRACTOR
--�
C. ENTURY140M:FS CONIM( N RI f tS
CEMURY HOAI S COMN11231'1"1ES
1535 solim1) STTY'EI' #200
19-305 C;AMl►NO DEL ORO
SAN BERNAici INO CA 92408
SAN OERNIARDINT, CA. 92408
(909).38J -6W7 CBL. 2120
(90)381-6007
DESIGNEWENGINEER
FR,ANY GONZ,ALES & A.SSOCT.AIT
133 Ltd` T CHAPMA�l AVENUE
USE OF PERMITS moi" % i"115 i. i vWL rL. Syi.�
ORANGE. CA 92666 (909)532-6878
RANCHO QC( Y `1U.,0 t4 LA QLRNTA NO;R'1'1
PHASE.;B PLAN2X
FEE DESCRIPTION
FEES
'1'l+:.Ac_'.t' t;f 1f_�{�t`T'kL1C: I'.lCl'N A.�tli7.tHD Via'
PGRG'1'"UPA"(TIO 168.0 SF
QARAGElCA tP(31Z.T 428.00 SF
ESTIrdA 1 QED COST OF CONSTRUCTION
110,133.30
1'li:.RWT FEE SUNIMA tY
LAN CH7;OK E.FE; 101-000-439-3168 RSi34.TsS
M10,C-0011 1U99,00
C0114'1,'10NI EE 101-000-418
11CCIIAMCA(,101-000421-00O 555.50
U'LECTRIC AL E'er 101-000-420-000 $IZ0>74
PTATURTNO FFR -1 1.0'140)419-000 5144.00
1111'r ONG; &.10-`1'f.0 lNT n7174 Y 1M:TaiT) W -(1()0-2<+j = $11.61
OR.ADINO I-' a-,' J O W00t}423-0010 520.0
!i<fa ;Ztk;f',l I2(JG"('LiAk !� Vii: 22.5-(ltKi-443-342 S %2.T3
IN1�'!"l'PLT1i1.tc.' Pf,nCES - RFSTf; 701.-0U0-2S�-t><1A %s(?.33
SUB -TOTAL CJNS"l'RtJG r10N A:N'p PLAN CHECK,
$4,25.3.76
LESS PRE -PAID :FEES
$0.00
� I TOAAL PERMIT 1:'F, FS DIAL NOW
$4,25&76
OCT 2 4 1995 T:OiTAL riROJE T PERMIT FEVS
4,259.76
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 17
Exhaust Fans
O.K. to Wrap 1
F.A.U.
FramingCompressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath iv
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 I I
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 z
Encapsulation
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: