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9510-002 (DSF)In LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with r W Section 7000) of Division 3 of the :Business and Professionals Code, and my o CUA co License is in full force and effect. r- License # / G r/ <-- uc. Class_ Z r Date r SiSignatureofContractor '.._ F- M OWNER-BUILDER,DECLARATION JIU - I hereby affirm that I am exempt from the Contractor's License Law for the 0- 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 O CNJ rn WORKER'S COMPENSATION DECLARATION dQ I hereby {firm under penalty of perjury one of the following declarations: Z (�)�ave and will maintain a certificate of consent to self -insure for workers' L <Cc compensation, as provided for by Section 3700 of the Labor Code, for the X W LL 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 3701189 t%ILabor Code, for the performanceloffth$6bbork for which this O U permit is issued. My workers' compensation insurance carrier & policy no. are: d Carrier Policy No. - ,. ? (This section need not be completed if the permit valuation is for $100.00 or less). cb ( ) 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 .8 Code, I shall forthwith comply with those provisions. Date: Applicants 00 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 3708 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 q4 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) Dads t ALC# BUILDING PERMIT PERMIT#9510-00 DATE ft,)/ -2195 VALUATION $ ji ROT TRACT JOB SITE ADDRESS APN OWNER CONTRACTOR Afi. & &[Is..Robelt Ro JAMES RUE CONSTRUMON 49-816 C031011011f) 01. .41651 C(.; RPORAT1+ NVAAY M A. Rr+;e t P 93705 (203)344-3858 PALM, DFSERT (,A, 92261. 4'.'T' ' x' T r' DESIGNER/ENGINEER USE OF PERMIT FEE DESCRIPTION FEES ` 1X;1N•10.1,1110N FEC 101-000-4234M $45.()0 TOTAL PERMIT 1♦'ENIN S457.00 i ,D OCT 0 2 1995 By RECEIPT DATE BY DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS y,-... 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 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 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 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: Bin # CISy Of La Quint7 Building 8r Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # Project Address:' 8 �l / Owner's Name: H �, A. P. Number: Address: 2'7,5�-—� Legal Description: OT 1 7 T �� 2 City, ST, Zip: �r� Q() Contractor: Address: Telephone: Project Description: `2 E 0 City, ST, Zip: +V) ✓ v'm A Vl fil. 00,Jt li Telephone:01� • State Lie. # : 14 i' City Li c. #; Arch., Engr., Designer: 1 `/ r5 Address: �((%� �� �� [A/0 h %J) Y74YI Gl 1:tJ 33 77, City., ST, Zip: (�� I ✓I T �1 a- "l �2� 3 Telephone: z..u.:.,.•,.:::::::::::.: State Lic. # Name of Contact Person: 1' l% I �� �, (� ]��I4�� Construction Type: Occupancy: Project a circle one): New Add'n Alter Repair Demo Sq. Ft.: (�� #Stories: I #Units: Telephone # of Contact Person: (p % �% % 7, Estimated Value of Project: 0,000. APPLICANT: DO NOT WRITE BELOW THIS LINE # Submittal Req'd Reed TRACKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Title 24 Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan 2". Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.M.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- '"' Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Total Permit Fees e, r iKITIMIM i r P.O. Box 1504 LA QUINTA, CALIFORNIA 92247-1504 78-495 CALLS TAMPICo LA QUINTA, CALIFORNIA 92253 BUILDING & SAFETY DEPARTMENT PROPERTY. OWNERIS .PACKAGE (760) 777-7012 FAX (760) 777-7011 Disclosures & Forms for Owner -Builders Applying for Construction Permits [MUTANT! NOTICE TO RItC�PE , OWNF.It Dear Property Owner. - Ari. application for a building permit has been submitted in your name listing yourself as the builder of the ,property improvementsspecifiedat1.2(� (°oaclie/% %�v:...�t Qu�kf4 G+ 12ZS3. We are providing you with an Ovin r-Buildec`'Acini6vvledgmeni'aiid Uiformatien erificatton Foim fa make you avviare of your responsibilities and possible risk you may incur by hgving tfi rmit.issued. in your name as the ----_--_- Owner -Builder. I mill no1issue a: building-pecanlf-untWyqu-tiay.e cead,- mtialed�your-understanding-of,-each'prodsion,-- signed, and returned this form to us at our official address indicated. An agent :of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. ONE'S ACA9jQLWLEDGI EN'T ASD E IECA`1. 'ON'OF M.OIIMATION DIRECTIONS: Read anti initial each statement below i signify you utiderstan&or verify this information. L I understand a frequent practice of unlicensed persons , is to have the property owner obtain an "Owner -Builder" building permit that erroneously implies that the property owner is providing his. or her own labor anii material personally. i, as an Owner -Builder, may be held liable and subject to serious. financialrisk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance -coverage for injuries to workers 'on my property. 1)�2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and arenot hiring a licensed Contractor to assume this responsibility - TV 3. I understand as. an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her naive instead of my own. LIM- I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. NO 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and. materials, I may be considered an "employer" under state and federal law. 6. I .understand if. -1 am considered an "employer". under state and federal law, 1 must register with.the.state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and' contribute to unemployment compensation foi each "employee." I also understand 'my failure -to abide by these laws may subject me to serious financial risk. .. , 7. I understarid under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the .intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four' within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. .VA. I undersiand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal. injuries sustained by any subsequent owner(s) that, result from any latent construction defects in the worlananship or materials. Try. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CS _13). at 1- 800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 1W10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and finan/cially responsible . €or, proposed construction activity f at the following address: �4 COcuKe(Lt1 11. I agree that, as the party. legally and financially responsible for this proposed construction activity, I will abide by all applicable liws and requirements that govern Owner -Builders as well as employers. Z. I agree to notify the issuer of this. form immediately of any additions; deletions, or changes today of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. IIf you contract with someone who does not have & license,. the Contractors' State License Board may be unable to assist'youwith any financial. loss . you may sustain as a result. of a complaint: Your onlyremedy against unlicensed Contractors may be in'civil court. It is also important for you to: understand that if anuttlicensed Gontractor or employee of that individual or firm is injured while worlang on your property; you may be held, liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be.rvsponsibie�or xerif ainLy- r not those-Contmctom-ami ropedy_ticemsed-and-the_s_tsittis of thc'il workers' compensation insurance coverage. Before a building permit can be issued, taus form must be completed and signed by the property owner and returned to the agency responsible for issuing; the -permit. Motor: A copy of th--.pr operty o.wner's dkive 'sitcOft form nOtacizatton; or .other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner �I�7�(itu. Date: O7 /a Note: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder. AUTHORIZATION OFAGENTTO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the exeeption of which: I understand, is my personal responsibility, I hereby authorize the following person(s) to act as my agents) top for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. n Scope of Construction Project (or Description of Work).: /( mac" e !X - Project Location or Address: 64 7 v Name of Authorized Agent: R2 6 _ZL h n e AIV V u 5 /< �'� Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the owner's driver's license, form notarization, or other verification acceptable to. the agency is requiredid. be presented when the permit is issued to verify the property owner's signature-. Property Owner's Signature: � Date: G DID % 3