9512-059 (MISC)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am I ' icensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code. and my
:3 ce)
r�. Cy n License Is In full force and effect. 184460
I- W r License # Uc. Class Exp. Data
rZ a: 'r-" Date Signatureof Contractor
Z
0
P: 6 OWNER -BUILDER DECLARATION
J 2 1 hereby affirm that I am exempt from the Contractor's License Low for the
�Ll a. following reason:
U) ( ) 1, as owner of the property, or my employees with.wages as their sole
Z compensation, will do the work, and the structure.le 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
ce) Date Signature of Owner,
U')
C\I
0 04
0 0) WORKER'S COMPENSATION DECLARATION
6: < I hereby Vfirrn under penalty of perjury one of the following declarations:
E ( ) I have and will maintedma certificate of consent to self -insure for:workers'
LO . compensation, as provided for by Section 3700 of the Labor Code, for to
T_ F-; 0
X W LL performance of the work for which this permit Is issued,
0 _J _J ( ) I have and will maintain workers'compeneation Insurance. as required by
J 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. we:
U)
0) Carrier Policy No.
11 Z_ (This section need not be completed If the permit valuation Is for $100.00 or low).
co :)
N C3 I certify that in the performance of the work for which this permitJ9 Issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califorrila, 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.
Date: Applicant
W, - arning: I Failure to secure Workers'Compensallon coveragdris 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 feesi
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 vold 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 4o compli with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-merWoned property for Inspection purpos".
Signature (Owner/Ageno Date
ALC 0
BUILDING PERMIT
DATE 12/1111195
VALUATION $2.800.1 LOT TRACT
JOB SITE ADDRESS
SX545 AVE CORTE2
AM
OWNER
CONTRACTOR
DAVID ARfFS
KxrnuEN s. wiuuxx
Ro� BOX 5(A
33-545 AVE CORTEZ
PALM SPRINGS CA 02263
LAQUINI-A CA -02253
324-5880
'171-3135
DESIGNEWENGINEER
U 3 E 0 IF P E R N M I S CE L L ANN, EU0 US'
SQLARSYSTal INSTAI.J." wnHour Pr"rr: owNEK No,rw*.,D TO Put. PJqtMn,.
CONIRACTOR USEI.) DOSE NOTHAVE, A Un'LICN
FEE DESCRIPTION
FEES
P(N-)L AND/ORSPA 2,300.04) US
ESTIMATED COST OF CONSTRUC710N
2,800.00
PERMIT FEENUMMARY
MISCEIA-AN1301LIS 101-000-423-Mli $00.;
'SUB -TOTAL CONSMUCIIONAND PLAN CHECK
LESS PkE-PAID.FEES
$15.00
S0.00
C �OTAL- PEP -MIT FErts DUE. 01V
OPT
f6A� 78Y
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
I DATE
I 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 Loc tion
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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Wiances
Final
Final
Utility Notim (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltne Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: