9512-095 (SFD)LICENSED CONTRACTOR DECLARATION
NI hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
C)
W Section 7000) of Division 3 of the Business and Professionals Code, and my
r, Ci u.) License is in full force and effect. 314473 B 1/31/96
N W ^ License #_ Lic. Class Exp. Date
ZDate Signatureof Contractor
H OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
CL following reason:
W ( ) 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
0 rn WORKER'S COMPENSATION DECLARATION
CL 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 �< 11 compensation,;.as provided for by Section 3700 of the Labor Code, for the
W LL. performance of the work for which this permit is issued.
J J J ( ) I have and will maintain workers' compensation insurance, as required by
n J 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:
1 LO Carrier Policy No.
Z (This sectidrVi eMvaitt643 ompleted if the permit valuatiol igf&4400.00 or less).
00 n :D () 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
c Code, I shall forthwith comply with those provisions.
0
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 perfomed 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.
i Signature (Owner/Agent) Date—
ALC 0
ate
ALCM BUILDING PERMIT PERM 111-31,
-wi
DATE r y~ VALUATION Vti.yx LOT JA TRACT z't v8
JOB SITE ADDRESS 79-290 CA�V1I NO AMARILLO APN 604492-021
OWNER CONTRACTOR
CENI MY HOMRS COMARINITIES
Cf?N'.PJRY` HOMES COMP►II. MMES 1535 SOURI 0 STREET -1200
153.5 SOUTH .D STREET #200 SAN BE.RNARDWO Cr'1 92405
SAN BE;RNARD:IN CA 92445 (909)3$1-6007 CBL# 2.1.20
(909)381-6007 DESIGNERIENGINEER
FRANK G£)N`ZALES & ASSOC,
USE OF PERMI RM. 7, ' P1 ,7. 1 d -4 133G EA.S"?' CHAFArIAN, AVE.
c; RANOR CA 92666 (710532-6878
RANCHO OCOTILLO @ LA QUIN rA NOR!I'E:PHA. E 3C
PLAN 4ALR
FEE DESCRIPTION FEES
TRAC`C CONSTPLAJCTION 2,818.00 SF
PORC"ATIO 1.68.00 Sr
GARAGiJC;.Ai PO'R'T 590106 'SF
T1C11 ATEO COAT OF CONSTRUCTION .166,815.84)
ir'E1i11UT V11,'E SUf1ut14fiA)RY
PLAN (ITWIICK FIE 1014MI-439-3#$ SMA4
CONSTRUCTION FEE 101-000-418-000 $374.00
MriCHANICAL l FIX, 101-000-421••000 Ua9.0U
ELECTRICAL M 101-040-420-040 S173.93 �
i'z_IMIRtN4 17117F? 101.-000-4.19-000
STONG Ai►C}TION;FITM - RESID 100-0000-441-000
GRAISINO FEE 101-000-423-000 V20..00 -
INFRASI RUC PURL-' 1 RS 225-404-443-342 $3,703
ART IN PMLIC PLACES - RESI:C 701.000-255-000 $167.
SUB -TOTAL C®NSIRUCT O r AND PLAN CREC,K $5.871.87
LESS P11.9 -PAIL) •FU $0.00
I ,
'JE'A L ER1lW FEES ID NOW sS,871.87
,D ,
i
JAN 0 8 1996. .
RECEIPT DATE' BV DA NA 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 'fes
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
09
Compressor
Insulation a6 57
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 PPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
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 AfHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection Ab &Vf
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL P OVALS
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: