9512-092 (SFD)cn LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
o j co Section 7000) of Division 3 of the Business and Professionals Code, and my
n d U')License is in full force and effect. 3.14473 B 113U96
�
LU n License # Lic. Class Exp. Date
Z Date Signatureof Contractor
CD � dh OWNER -BUILDER DECLARATION
J IU 1 hereby affirm that I am exempt from the Contractor's License Law for the
a 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
rn WORKER'S COMPENSATION DECLARATION
a Q I hereby affirm under penalty of perjury one of the following declarations:
o Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
In H O Cc compensation, as -provided for by Section 3700 of the Labor Code, for the
XW LL performance of the work for which this permit is issued.
Q 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 V permit is i§' U� .)IMVLh others' compensation insurance caf"ribrO' policy no. are:
Carrier Policy No.
Z (This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
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: Failureto 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 for inspection purposes.
Signature (Owner/Agent) Date
ALC III
U_ILDING PERMIT
� PERMIT���� (9y�
DATE ie/119`1a...
VALUATION w' "!'''' ` LOT '" TRACT
JOB SITE ADDRESS 79-260 i:AMINO AM"IL 0
APN 604-192-020
OWNER
CONTRACTOR
CE'14'1URY JNOM.ES COM11 UNTTIFS
C'.UNI T'URY 1-TOMPS COA1MC.Tt�IMES
1435 SO►.,i 11 D STREET #200
I535 SOM D STREET ##ZOO
SAN BEI NARDTNO CA. 92408
SA.N BE.RNA.i DIN- CA 92408
(909)341-600 Cl31_N 2120
f ��)181-wl
DESIGNERIENGINEER
T'1 MK. GONZALES
- - '
L336 BAST CHA1'.>tiIAN AVENUE
USE OF PERMITS lit -f 3, V V
ORA1` GE, CA 92666 (714)532-6878
tiANCHO OCO TLLL.O LA QL)Lb]`.!'A'NORTH 1'.i'LA,SE 3C;
FLAN 3T Ti
FEE DESCRIPTION
FEES
TRACT CONSTRUCTION 2,4456.00 S
GARAGE/CARPORT 880.00 8F
ESTIMATED COST OF CONSTRUCTION
I34,xS1.13f3
MMMIT FEE SUM MRY
1L. kN CHECK FEE 101 -Uig -439.318 S68S:98
eon CA
C0NV1 Ri.itC: rN, SN FEE 101-0004MOW dean. cn
,401GAIJU
WC4kiANICAL FES N-00"21-000 183.00
ELECTRICAL lE 101-000-420-004 $162.41
P1.1IM79i'mo x'MR ilii-Q9Q-Aj9-(jM R144,0
STONO MOTION,t'M - RES1O 100-400-241.-000 $15.12
GPADING FVT, 10.1 -000 -4'23 -WO $200)
Tf1F A5TRtTC'TURF, 1T 225-000-443-342 33,400.90,
ART IN PUBLIC PLACES - RF -'q ,' 701-000,255-400 $i27.R9
fJ<JB OIML lrON,' .i.b\YVC/ 104 xUND PLAN �n..MIC'K
$,5,!465.31
LESS ME -PAID FEES
10.00
TAt+ PE, WI 101�'ES DUE'Now
$5.,464.81
ri 1996 a
RECEIPT I(" "
DA
BY
DA
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPRO ALS
MECHANICAL APPROVALS
Set Backs'
Underground Ducts
Forms & Footings
Ducts
Slab Grade 0
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 s
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final tie
POOLS - SPAS
BLOCKWALL APPROVALS
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
Final
COMMENTS:
,
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)