9512-096 (SFD)cn - LICENSED CONTRACTOR DECLARATION
N 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
co
CD C) Lo License is in full force and effect. 314473 13 1/31/96
n � j License # Lic. Class Exp. Date
Z Date Signature of Contractor
0 r`
OWNER -BUILDER DECLARATION
J U I hereby affirm that I am exempt from the Contractor's License Law for the
LLI
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
CO Date Signature of Owner
Orn WORKER'S COMPENSATION DECLARATION
FL Q I hereby affirm under penalty of perjury one of the following declarations:
Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo Cc O compensation,' as provided for by Section 3700 of the Labor Code, for the
X W L!_ 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
C5 U permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn H , Carrier Policy No.
"? ? (rhis sectlorineetl tit lZ�t ompleted if the permit valuati6t fdd$100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
C) 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 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. f
Signature (Owner/Agent) Date
ALC8
BUILDING PERMIT
PERM"Osm w.,
I
DATE 1&1979J
VALUATION ST40W.3.2u LOT :.:
TRACT 4-.1
JOB SITE ADDRESS 79 295 CANUNO AINIU il,LLO
APN 604-1,97-11.14
OWNER
CONTRACTOR
CENTURY HOMES COMN-fUNMES
CBN`Iivx I om,,#i5 COMMuNnus
3535 SOUM D STREET EEE IP2I10
1535 SOUTH D Si' E01' 16200
B'ERNARDINO CA 92408
SAN 'BV -,RN, RDIN1 CA 92408
(910381-6007 CBL# 2120
(9119)381.,-6007
DESIGNER/ENGINEER
FRAT%N' OONZAi.ES Assoc.
1336 EA a`.I' CHA MAN AVE.
USE OF PERMIT+ NL: L1ti 1-JUVILL Y OWELLUNtJ
ORANC13,. CA. 92666 (7'14 S32-68713
RANCHO OL"O'1' ,LLO fg LA. Qi1'INI.'.A NOR fC P.kiR�S . 3S;
P'6 AN 4
FEE DESCRIPTION
FEES
TltAAC r CONSTRUCTION 2,436.00 S1•
PORCUMATIO 16$$.00 S!%
0Al2AGIFICARPOWY 5°.70.00 Sl: V
.E.`STMA•TED CAST OF CO1 SURUCTIOiN
146,07.3.244
P.F.JRMfF FE,E SUINIIMARV
PLAN CHECK FEET 101 -0(t() -439-M $656 .75
CONSTRUCTION FTE 101-000-418-000 $804.00
iMECHANICAi.. J•'F..lr 101.000-421-M $49.00
ELECTRICAL Pta'13 101-0(10-420-000 $160.56
.PLUM11ING FEE 101-000-419-000 $130.00
STONO.ti10'rm Fm, - li. siD 100-000-241-000 $14.611
ORAi1INO FEE3 10.1-000-423-000 $20.00
tN RASTRUCTURE FEE 2225-"000.443-'34`2 $3.236.:17
AK'r rN P1]BmC PlACES -1EST1)701-000-255-CM
' e
SUB -TOTAL CONWR.iJC ION AND PLANT CHECK ._
. ' Y $5,214.47
Q LESS PRE -PAW FEES
$0.00
! n
TAI:. PERMIT FE,18 0(f E NOW
S5,214,47
JA N O.8 :1996
RECEI `T
DATE
BY
D T N E
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APP VALS
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 6
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 A PROVALS
POOLS - SPAS
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 over
Sewer Connection
Encapsulation
Gas Piping
Gas Test L
Appliances
Final
Final p IL
Utility Notice (Gas) '391211th az
ELECTRICAL WPVkOVALS
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:
-
11 .