9511-111 (RR)P- LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
r, C) U) License is in full force and effect.
r�. WW n License # Lic. Class Exp. Date
r- Z Date Signatureof Contractor
crp H OWNER -BUILDER DECLARATION
J IU I hereby affirm that I am exempt from the Contractor's License Law for the
W following reason:
IL
U) () Iflas 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Cade).
() I am exempt under Section B&P.C. for this reason
� „ Date N'& (PKI
rn WOR ER's C0111� E" 446N DECLARATION ^
4. Q I hereby affirm under penalty of perjury one of the following declarations:
MZ () I have and will maintain a certificate of consent to self -insure for workers'
A v I compensation, as provided for by Section 3700 of the Labor Code, for the
W W r Zperformance of the work for which this permit is issued.
J J S () I have and will maintain workers' compensation insurance, as required by
n Q U q 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:
L rn y+ Carrier Policy No.
.?'� (This section need not be completed if the permit valuation is for $100.00 or less).
CO (OA -certify that in 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 rSection 3700 of thel abor
e Code, I shall forthwith comply with those• provisions.
ate: Applicant }
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
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 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). / r Data
"`°0
BUILDING PERMIT
PERMIT���
DATE . !L lY.�
VALUATION T TRACT
JOB SITE ADDRESS52-190 AV& CORTk, Z *
APN773-202-010
OWNER
CONTRACTOR
d
OWrNEWBUD,DE,R
HILAR10 IGYA RZAT
52190 ANIEKIDA COWITZ
LA Qi1IWA CA 92252
C.13L#
(
DESIGNER/ENGINEER
USE OF PERNUENERAL BUILDING
!2 ROOF
FEE DESCRIPTION
FEES�:l
TdJ~RC)C7P W0.0 t S
TJ viATED ai .PST OF CsiINSTRU0411O
1k'MMrf 1 C, E, 8UAiMARY
RFI2OOF f: H9 lot -000,418-000 $30.00
1.
SUB-TOVI CONSMUC 100 AND PLAN CHECK
$30.00
LESS IRE -PAID FEES
ISO.00
TOTAL PERMIT F EIRS 1 DIE' NOW
S30.00
n
TOTAL € RO.3ECT P1RR1iITT FEES
30.00
RECEIPT.
DATE
BY
DATE FINALED
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 Wali 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
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
-
„
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