9601-026 (PLBG)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.
License # Lic. Class Exp. Date
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
folloyvinng 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. forthis reason s
Date1_. � .�'"r�Si nature of Owner / r. _.- „ f/ ✓
y
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 section need not be completed if the permit valuation is for $100.00 or less).
)certify that in the performance of the work for which this permit is issued,
I s all 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 3700eof the Labor
Code, I shall forthwith comply with those provisions..,
ate: Applicant /rte. /✓r"� %� .f, .�' �:�c:
f �+ / ! i Lr•
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
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 wcrk 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 iinspection
`Kp�urppooses
�/�/.Akgnature (Own/
..Dats
-"
ALCM
BUILDING PERMIT
PERMIT 60.IA2b
DATE 1/5/96
VALUATION $la0WR
LOT TRACT.
JOB SITE A DRESS
APN4-06,9-007
OWNER
CONTRACTOR
OtNEWvALDER .
CURTIS D L II,LIAM- S "
53148 AVENIDA NAV RRO
LA QUINT,A CA 92253
CBIJ
DESIGNEWENGINEER
USE OF PERNPLUMBING
SEWER C0Ng4FCT
FEE DESCRIPTION
FEES
CON'17RA-C i' AMOIJ1+i'i 1,0fs0.00 is i
:�,.v5T1A1XfCD COST OI{ CONST �UCHO
�; �1i'p�p� A
yy q, pppp��yy+� FEE
PUUMD.ING FIFFE -- :1EWER. 101.000-419-000 530.00
Q
SUB-IX)e'AI,, CONSTRUCTION AND PLAN CHECK
$30.00
LESS PRE -PAID FEES
.$0.00
TOTAL I'EIk8MIT FE &S !?ilENOW
$30.00
RECEIPT
DATE
By
DATE RNALEDINSPECTOR
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
CK for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final f
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:
1t.V7,7"'. 't a,-_Lill;,"A'.::... !"'Az
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: `�� �' `✓//
Address: ��
(� �.
Account No. Lot s)
Service Address �'-- /G r- i %•
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
❑ MMeeW96rcharge
L� Sanitatlon Capacity Charge �� a
❑ W.S.B.F.C.
❑ Temporary Construction. Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
G.A. Code
Remarks:
❑Copy to:
Cash
Check
�� .I'•
Money
Order
TOTAL $
Water Service
Cashier -�'
CVWD-438 (11/89)
Ve& s
M3iHng Address: Box 1255 'PALM DESERT,. CA 82261
Phone: 328-6718 / 346-6916
Catlf. $tate ContramW Ucettss No. 310813
r 11h "n S ❑Owner
�_
Name 44 W ! '' ❑Tenant 1211111to
C� bar
Job at ` 1 t� >o:i „a.2a o At
City ZIP city aP
N? 66079
DATE l — b
WORKMAN^
Old Customer ❑ New Customer
Claaification
Telephone ( )
WORK AUTHORIZATION - I / We hereby authorize the work descn'bed *ng with WORK ORDERED:
the necessary materials and parts
Time From To Hours MATERIAL USED AMOUNT
Mon.
coo p -C�
Tues. '
1
Wed.
r,; tic,
Thurs.-
Fri.
gin
Sat
J4C�. �. i / !9 t^- ►� j}
Sun. ,
R "d A,
Total Hours
ENTERED
Involoe-
Joumai
Ledger
Cards
yyAVER OF RIGHT TO CANCEL
Havipg Initiated a contract in connection Neth emergency
repairs or sernce for the immediate protection of persons or
real and persorw� property, I hereby state that the rgllowing
emergency siWation exists, requiring invnediate attention:
Pursuant ed�ge and section
wai a al�ghts ttomcancia ceel the to
within three days.
Dated Buyers Signature
TO OUR CUSTOMERS: Service men are required to have work slip signed. This Is done in order to protect you, the workmen, and ourselves, and
to enable us to give you absolute satisfactory service. You are respectfully requested to examine material and labor statement before workmen
leave the job, and if you find everything satisfactory, okay this tidtet If service is unsatisfactory, in any way, please phone our office
Immediately. 1 find the time and material ctiarged above satisfactory and agree to µay kr same on presentation of rnvoice, and further agree to
pay reasonable charges for collection, including attorneys fees in the event of rrry de * A PENALTY WILL BE CHARGED AT THE RATE OF
itrz% PER MONTH ON UNPAID BALANCES AFTER 30 DAYS OF INVOICE DATE. ANNUAL PERCENTAGE RATE 1e9t;.
Contractors are required by law to be licensed and regulated by
the Contractors'StateLicense Board. Anyquestionsconcerninga Signed
contractor may be referred to the registrar of the board whose
address is: Contractors' State License Board, 9835 Goethe Road, BY
Sacramento, CA 95827, P.O. Box 26000, Sacramento, CA 95826.
Total Material
Tax
Senfloe
Permits' Insurance
Trucks -Equipment
TOTAL
01995 by John B. Reeves & Son Ewes BUSINESS FORMS -era wamar oaW,CamrClty.CAe0Q8tt Form 31 WAG