9602-046 (ELEC)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
LicensErls,in lull force and effect.
License # LiEtN' Aasi B Exp. Date 2129196
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 secti'&h1h&6dA6'F15e completed if the permit valuationi'r7f&i $1bb.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: 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
fora 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 Al 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. r
5re (Owner/A9ent)
v
ALC0
BUILDING
PERMIT
PERMIT'
li.4d 'A da.d 1.
DATE 217196
VALUATION M,419.5;
LOT
TRACT `
JOB SITE ADDRESS
APN
9 'aafl •AA T Ti' P A Ir 01%.1
40 1 2A VMA
OWNER
CONTRACTOR
1e
LENDS .'VENTURES
SHMMON R L.CMEN TNC
8361 VICKERS ST, Slat 30
31140 CAL.L:E PALOIbIA
SAN DIEGO CA 921.11
LA QL11NTA (A 922.53
r91 A 4 9, 4 os a oea
DESIGNERJENGINEER
USE OF PERMIT
ELEC"d' MEC1J/PLUA4L3 CONiE3L"+LV10'.
RFA4000, i.AUNURY AND (1) SLN'01:6 CAR GA[BAGEn' AMA(185 (185 S.F.)
FEE DESCRIPTION
FEES
BONUS Ploom 1is5.Gti SF
ESTINIA`I`1 D COST OIr CONSTRUCTION
6,41.9.54)
PERMIT IEEE SUMMARY
PLAN CifWK FEE 101-000-439318 $58.50
CONSTRtlMON FEE 101-000-=118-000 s90.o0
NI1ECHMACAL FhT:' 101-000-421-000 $1.5.00
aE-C`t R1CAL .FEE 10I. -0()t)-420-000 $21.=18
PLUMBiN•G FL'E 101 -000 -419 -WO $.33,00
;3TONG NIO T1CIN 1 -TE - R�SIL) 101-000-211-000 $.t',4
/ SUB -TOTAL. CONSMLfCI'ION AND PLAIN CHECK
$218.62
;o LESS FERE-PAID PEES
$0.00
TOTAL PERMIT FEVS DUE NOW
o
$218.62
FFA
ey 1996
RECEIPT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Ftiotings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.
F.A.U. "
raming
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath Q ZQ
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
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:
Final Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Desert,:Sands:Unifed School'DistHct
Notice: 82=879 Highway ,l l l
Indio, CA 92201.
Document Cannot Be Duplicated 619 775 3500
CERTIFICATE' OF COMPLIANCE
Date 2/7/96 i';: APN # 769-134-001
No. 14125 Jutii eilon La Quinta
Owner Name Sheldon R. Zemei; Inc. Permit #
No. 51140 Street " Calle Paloma; ' Log #
City La Quints Zip'= .92253 = Study Area 116
Tract # Lot # ..Square Footage_ ' 185
Type of Development Residential Addition No. of Units 1
Comments
At the present time, the;Desert Sands Unified School District does,not collect�fees on.garages/carports,
covered patios/walkways; residential additions under 500 square feetidetached accessory structures or
replacement mobilehomes.� It has! been determined AM" 6Vd named' owner 'is exempt from paying
school fees at this time due to the following reason:
EXEMPT
This certifies that school facility fees imposed pursuant to G'overnment.:Code 53080
in the amount of 0:00' x 185 or $R:00.•
the property listed above and that building.permits and/or Certificates of-0-ccupa cy for
this square°footage in this proposed project may now be' issued.
Fees Paid By N/A Tele ho�e4
-1861
p ;554
y
Name on the check': c
By Dolores A. Ballesteros
Superintendent.
-'Fee collected /exempted -by Pauline Pearson Exempt $0.00
n Check No. N/A
Signature
PA. ; �� It, A All
Collector: Attach a copy of county or city plan check application form, to district copy for -all waivers.
Embossed Original- Building Dept./Applicant Copy - Applican*/ ceipt Copy - Accounting ,