9602-099 (BLCK)u) LICENSED CONTRACTOR DECLARATION
N1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
LU Section 7000) of Division 3 of the Business and Professionals Code, and my
n O � License }a in full force and effect. 533670 i3 6/30196
LU, 1 License # Lic. Class Exp, Date
Z \Date'i` . , Signature ofContractor
�_" ._ ..
Pr-
F- `
o) OWNER -BUILDER DECLARATION
J lU 1 hereby affirm that I am exempt from the Contractor's License Law for the
CL following reason:
Z ( ) 1, 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).
( ) 1, 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
N
rn WORKER'S COMPENSATION DECLARATION
EL 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'
L cc O 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.
O 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
O U permit is issued., My workers' compensation insurance carrier & policy no. are:
d rn Carrier GOi.D1sN'EAGIJE Policy No. PvdC27ZI77-00
1* Z (This section need not be completed if the permit valuation is for $100.00 or less).
I` a() I certify that in the performance of the work for which this permit is issued,
d 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:� �a/Applicant
y� �"''
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
who3a rayuest W -id fui 4whub* beriefil wuik is Nerfumied under ui pulsuarrl 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.
Sig re (Owner/Agent) r.�«-err'•",' - F
,� v. r Date O -A4
ALCM
BUILDING
PERMITPERMIT4o""
DATE Ll1YO
VALUATION , ••y
LOT
TRACT!!
JOB SITE ADDRESS SW62-5 ". LLE OUI TO
APN
I
OWNER
CONTRACTOR
SUNROSE CO.R110Ri1.TION
SUIROSF CORPORA710N
72-850 SOMERA Till,
72.8,50 SONI R -A. RD.
PALM DESEWr CA 92260
PALM. DE R. CA 92260
(619)346-2810 CBI,# 1137
(619)116-2940
DESIGNERIENGINEER
USE OF PERMI'Ptlx 7: Itti:t f61tLu !v
90 Lf, of 6' tugfb mtd 13411 of 54*1 pudalt block. w1111
FEE DESCRIPTION
FEES
FT. WALL 134.00 W,
6 Fr. 'WALL 90.(10 LF
ESTIIINIiLTE D COST 01F CON STR"I.ICTs`GIN
5.$15i.'A11
PH;Itl« T > LIK 4i11'N.MARY
C_0NS1"KT.ICTT0N T- R 101-000-418-000 Sff ] .Oil
ST;Q-'iO`r ]. CONSTRUCTION AND PLAN CHECK
$81m
LESS PILE-I'AID FLIES
O TOTA PERMIT F MUV9 DUE NOW
$0.00
$81.00
190199
ley
RECEIPT
t)'AT ,�
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
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam G
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final3
Gas Piping
PLUMBING APPROVA
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
?Apt
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b.
a
BY _------
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