8603-034 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of,Chapter 9 (commencing with
Section: 7000) of Division 3 of the Busin s and; Professionals Cole, and my
License is In full force and effect. t� s and,
my
# Lic. Class '� Exp. Date
Date '-; Signatureof Contractor/
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) 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
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This sectiofi "nee not be completed if the permit valuation is` fo $1 :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; 1 shall forthwith comply with those provisions.
,Pate: Applicant
Cl -
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 rePtesentatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date -
ALC #
ais
ALCM
PERMIT
PERMITt�►r},-N
rRtn1B,U,ILDING
DATE
VALUATION
l0T
TRACT
JOB SITE ADDRESS IIX U /i) . [-'' I[1i +dt"
APN 040 -4.19 -VU f
OWNER
IITPe.0
1yiE'()RTA(._.E),.s tSL CpJ1S
OWN
411910 BOARDWALK YA2
48 070 PASO "i'IEMPO Liv
PALM DESEK-11 CA 422uu
LA QU1N`I'A, CA 922t?
{tilt') 9U -9(1U0 t"fi X :SSS
DESIGNERIENGINEER
or it" * .`ww"t IP k!? A
!196 OF PERIAT
Y RY.Al2 YAM) SKrl3A,( gti; RWA7VTT0N APPI2OW-D PFR 811A-396
FEE DESCRIPTION
FEES
POOL ANDl<_W fi-PA, 11,titK).0i I..i
ESTIMATE,D COST OF CURN'I'Ri14.',TION
11,000.00
PFIR11 IT P'IT SOMI IARY
tit :tkN CIWt K VVV 1014"Y'130-318 t131 �(t
t'ttlt,7P'N1'la't: (01(}(10.113.000 $126.W
Nif.1:11HNWAI Pill., 0..9 4, 101-000-121.01 S24,0
f�f.h'I'I'It14"t1a.}�1�1s P(JO1_ 10 1 -(11)U -4204Y.10 14% IV)
I'i I INII 41 Nt 1 '14, V V4 It)) 101 M1111941l10 "I loo
SE�1.i "CU'1'AL C'fJT>1'S11�11C' 1Ii7N AND PLAN CHECK
LESS PRE; MIJ FET,S
$0 U0
�TAt, PERNtit'I' 1 E.ES 011E NOW
1996
RECEIPT
DATE"�
BY
DATE RNALED•
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
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:
T�
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)