9603-035 (BLCK)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 # Liclaf"s — r'Exnp. ate 4i3W96
Date I Signatureof Contractor 77 ,\ Q
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).
O 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.
( ) 1 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 sectiop, need not be completed if the permit valuation is for $100.00 or less).
O I certif0h4kilin 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 spall forthwith comply with thoset;provisions-)
Date: (, Applicant �� •# �� J\�)I,- ItA....-
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject ,an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes. /
Signature (Owner/Agent) �. i 1' ��= GV,, Date
I
ALC
i i'
BUILDING PERMIT
PERMITi
DATE 1114t%
VALUATION s* 9�
LOT
TRACT
JOB SITE ADDRESS
APN
54.7.5.5 NiiSPFR0
OWNER;
CONTRACTOR
SAils
WYLLW(LD CA 92549
LA Qk)(NFA CA' 92253
fiA 101776_1 7RR (11411i
DESIGNERIENGINEER
(o o)* I ,0:i l0
USEOFPER"'TGE vI;K.t L BUILDING
104 L.F. OF 6' Hl(,}% 421..1%. OF N HIGH 0ARD N 'WALL. S71. F. QV Y8- C0f4 BINATK)N WALL (-2
RFT.); AND 6fr I'6" GARDEN WALI..
FEE DESCRIPTION
FEES
6l'"1'. WALL, Il►4.€.NI.LF
+ 15
FT. WALL 129.00 LF
�i
! F-STIMAUD COST OF CONSTRUCTION
!'ER1Yi kEE St1M')V ARY
CONS7;12UC nN F'fY 101.OW-41$-000 SRI.UtI
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SUB -TC TAL CON191RUCTION, AND PLAN `k ECK
$81.00
LESS PRE -PAID FEES
$0.00
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S�3i.lN3
i
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
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_7
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
Final
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: