9601-053 (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 Business and Professionals Code, and my
License is in full force and effect.17$ `s53 1Ua'31/96
License dSllass ° 'Exp. Date
Date —/ _ "S 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_; r r�satt: Policy No. Wal4�a.: I
(This section need not be completed if the permit valuation is for $100.00 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, I shall forthwith comply with those provisions.
Date: Applican t'7
Warning: Failureto 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.
Signature (Owner/Agent) r ` Date
A"'
BUILDING PERMIT
PERMITi� mis
DATE '(� (�
VALUATION 4a1t,4f1� 01 LOT
TRACT
JOB SITE ADDRESS
APN
79-05 R,ANC110 LA Q1i INTA tint
OWNER
CONTRACTOR
C'ALIFORNI'A POOLS & SPAS
'1' 1) DFSFRT nULLOPMENT
41010 BOARTAVALK #A2
P.G. BOX 1710
PALM DESERT CA 922x0
LA Q1}1NTA CA 92253
(619040.9000 CB" 355
DESIGNER/ENGINEER
771-1041
USE OF PERMIp00L Al aVOR SPA
1K X )I,, SPA. trt,A,IWAIN (. KY
FEE DESCRIPTION
FEES
2°C ,)L AND/Olk SPA 18,400 tit► 1.8
FSTIMXFc D COST OF CONSTRUCTION
18,400.00.
PERMIT FEE SUMMARY
PIAN CIMCK F -W 101-001-434-315 $1 N.n0
(7,(_) IS*TRUC'r1 )N FFE 101-000-418-000 sl". .00
b.LE(TRWAL I -E s -- POOL 1014)00-420-000 S43.iA)
I'Itrnf131 NO FEE -- Int 3(al I01 -000-419-00H0 S27.00
C'
IVF('HANWAI. FVX -- P001. 101-000-421 AM $2.1(N)
Z
Q
SUB -7 t-)TAL (ONS"TR11t:"T ON AND P zkN CHECK
542270
LESS PRF •PAIL)F1 ES
$0.00
TS)`1'AI, PERMIT FEUS D4 JF NOW
$422.70
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
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.Kfor 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: