9512-054 (RPL)ALC M
LICENSED CONTRACTOR DECLARATION `•� .t
I hereby affirm that I am licensed under provisions of Chapter 9 (commencin with DATE 12/fl-
,Section 7000) of Division 3 of the Business and Professionals .Code;, and my .
�. ic�nse in full force and effect._ ! / JOB SITE ADDRESS
License# �Uc..Class---, "Sip. Date An /'- OwNER
-bate f2 lit M. <* Signatureof4ntractor J/ TIGNA0
I hereby affirm that I am exempt from the Contractor's License L.hw1for 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 G�� Policy No. t�a�un.
(This section need not be completed if the permit valuation 4s for $1.00.00 or less).
() I certify that in the performance of the work fors which �tiiis�permit is issued,
I shall not employ any person in any manner so as become subject to the
G. ...... r r r
workers' compensation laws' of Californ'iia`, and agreefthat if I should become
subject to the workers' compensation provisions of lSection 3700 the Labor
Code, I �haly fo with-cornply with those pro�yisi s'.. d
Warning: Failure to secure Workers',Comp nsatiooverage is unlaw'l 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 j
& 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 wil.i.subject permit to cancellation.//41
I certify that I have read this applic
correct. I agree to comply with all
construction, and hereby -authorize
U
it the above informati6n,
�is
ws relating to the building
this City to enter upon the
5:1,340 AVE. KAM
MAJESTIC HOMES NORTH PA.R114ET
P.O. BOX 76
LA QUTI '1'A CA 92253
USE OF PERMITJOOL .AND/OR SPA
TOOL .AND/OR SPA
PERMITS
"12-054
77X04X008
CONTRACTOR
AMERICAN POLI, CO'NS'rRUCF10N
68575 Sart Felpe :Rd-
caEtiedial City CA 92234
(619)329-2156 C B1, 1"r 1104
DESIGNERIENGINEER
11,640.001.5
ltsl'i'tAVV ED COST OF CONSTR3 �C ilON
1'3+'.3110'1:1`1.' FEE Si[1:MAIARY
PLAN CHSC.K FEF, 101-000-439-318 $87.75
CONSTRUCTION FM tol.-W0 418-000 $1.3.00
141L'C13"ICA1, FFM -- POOL 101-00£3-421-000 $240
]IR— WrRICAL k"EE -- POOL 10140()0420-000 $45.00
P.LUNMI['NG FEE, -- POU1: 1010(10-43.9-00(3 $27.00
SUI3-T t1iC°C)N5TWC71ON AND PLAIN CHECK $318,75
LESS PRF.-PM.D FEES $0.00
TOTAL 6'Lr�''Ril�.l`c�Fir,ES DUE NOW �:laS.73
1.1 1995
RECEIPT I PDATE [BY IDATE FINALED IINSPECTOR
INSPECTION RECORD
•_OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
41, 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
117 1,17 f j
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Z /
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
Z?/
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low VoRage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)