9602-031 (SFD)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. 4892.34 B1 e
License # Lic. Class ,� . Exp:'Date-
Date Signatureof Contractor
OWNER-BUILDER•Df-CLARATION , a.
I hereby affirm that I am exempt fro4othe Contractr'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 sectionRptcVL%y q completed if the permit valuati%n`8195fl00.00 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 p'fovlstons,of'Seotion 3700�of the Labor
Code, I shall forthwith comply with o�.A Owsi ns-
Date: Applicant/'
r,
Warning: Failure to secure W Ike s' Compensation cover' ss unlawful and shall
subject an employer to CVf1al penalties and civil fines up to $100,000, in
addition to the cost of compensation,' damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his.application.
1. Each person upon whose behalf this application is made & each person, at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of tliis�applica'on agrees to, & shall, indemnify
& hold harmless the City of�ii�i:�rW' , I1officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for ins"pecti n,puTpos .
Signature (Owner/Agent) !{ Date
A`Cx
BUILDING PERMIT
PERMIT�12
DATE V 6/96
VALUATION .5121,684,1Qf
LOT 1116
TRACT 23913
JOB SITE ADDRESS
44-740 000TILL0 D���I�1ir�i
-OWNER
APN
6(W-26.5-003
CONTRACTOR
ROGER SNE T-,i,ENBER(3) It &A.SSOC.
ROGER Srii7i` L L NIt` ER,, rh'R & ASSOC
418..�i5 BOARDWALK X212
R
-.,41803 80AWWA.LKV212
,
PALM.DES'ERT CA 92211
PALM DESERT C.A. 92211
(619)177-7760 083114 .145$-
(019)777-,7766
DESIGNERIENGINEER
-
(7HAJRL1-;S D. OARLAND
33-163 CATKC'U,RAL CAMON DR.
USE 0FPERMI1>ING-1X FAM)..LY DWELLING
•
i -i T 777^ 0 AT 1-14* 9 0994
QU.If>3'i':HIRRA.
PIAN T
FEE DESCRIPTION
FEES
_ r
- • l e M7J' WNTV t.UCT.10N 1,01s-00 S'F
CFAA2Ac'£P cARP+7iz'.1 452.6.60 SF
E"WrIMATED COST O (.'0NS 1-KUCT1.01N
des,: ,> �►
PIERN ,IT FEE SUMMARY
P1,AN CFfFCK. FM 101-000.439-11$ S,597.Q6
C0NSa'R(JC'1'I0N FE- E 101-000414,000 $71.6.50
MECHANICAL. Va 101-000-421-000 &53-50
f.-BC.1R.1CAi, FEE 101-0011-420-000 3131.ss
rn
PLU-NMINC:VFM 1014W-41.9-000
3TONG A40 TIL 10141:'`3 + - RE, SID 101-000-241-000 31 G.1
C 1—WIN6 V0 101-000-423-000 $20.00
�
c�
iT+TF RA.gTRUCTLRE FFE 225-M&A4'<3-342, 52,737.0
Q M
:(xR.T IN k LIDLSC' V T�,A(,ES - RESID 701.000-255-000 $54,21
L
SUB -TOTAL CONSTR.'UC"flON MD PLAN CHECK
476,88
LESS PRE -PAID fEVS
1100.00
TOTAL- P ERNIff FEES DUE ?1101
$4,476.48
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 JPOOLS
BLOCKWALL PP OVALS
- SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
-Gas Piping i
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines A
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 G!
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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)
III