9511-047 (BLCK)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business end Professionals Code, and my
C) M
rl. Lf')
License is in full force and effect.
Q
n w n License # Lic��'Cl�s 4 2 . Date 30/96
m Z . =Date %gnatureofContractoAaw
,t
0 OWNER -BUILDER DECLARATION
J IU I hereby affirm that I am exempt from the Contractor's License Law for the
d following reason:
cA ( ) I, as owner of the property, or my employees with wages as their sole
Z 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
�
Date Signature of Owner
N
O rn WORKER'S COMPENSATION DECLARATION
L)
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'
WO compensation, as provided for by Section 3700 of the Labor Code, for the
K W LL performance of the work for which this permit is issued.
Z) J J ( ) I have and will maintain workers' compensation insurance, as required by
MQ U Section 3700 of the Labor Code, for the performance of the work for which this
J U permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
,? Z (This secti6h/h. ' nd `b6 completed if the permit valuatio i for $100.00 or less).
co
a() I certify that in the performance of the work for which this permit is issued,
O I shall not employ any person in any manner so as to become subject to the
workers'rcompensation 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.
E9 Date: Applicant
Warning: Fail ur'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 representatives of this City to enter upon the
• above-mentioned prop�ffinspecbon purposes. �
Signature (Owner/Ag
^I�
ALC
BUILDING PERMIT
PERMIT
941 IJAA7
DATE ilZ�.a;%9�1
VALUATION��.��♦
LOT
TRACT
JOB SITE ADDRESS
APN
A9 -90-S A ME. FT, M,
OWNER i
CONTRACTOR
HAMIL73N MASONRY
.AA RLON HAMILTON
P.O. Box 17-1
P.O. BOX 1771
LEI QUINT.A. CA 92253
L.AQ jfNTA CA
efriQlIAM%-'1!C4 ( i'sif 1!v3i
DESIGWER/ENGINEER
(
USE OF PERMIT -,
GEN.UtAL RU11DING
80' of 2' high ea tainilip wall with 61 high garden wall.
FEE DESCRIPTION
FEES
6 FT. W.4LL 80.00 LF
EST1'LMlTED COST O+ CONSTRUICT ION
2,000.00
?%R tg•p&. SUMMARYCONSTRAIC
i'ION:F EE 101-000-=1t8-Sil1A .345.00
SUB -TOTAL CONS`I'RUMON AICD PL.101 CHECK
$45.00
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES i311E NOW
S45:tl4i
TOTAL PROJECT PERMIT FEES
4&00
RECEIPT "•`
DATEBV
DATE FlNALED
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 Wali Insulation
Condensate lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - S_ PAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings i 9
Main Drain '
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVA S
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
UndergroundConduit
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)