9603-001 (RPL)LICENSED CONTRACTOR DECLARATION
C,J
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
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W Section 7000) of Division 3 of the Business and Professionals Code, and my
C:)= M O License is in full force and effect. _
r ^ License # Lic Ci ssi C�-•E&P,oatf.-
Z^t~ Date, SignatureofContractcr
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c0 H rn OWNER -BUILDER DECLARATION
J 0 1 hereby affirm that I am exempt from the Contractor's License Law for the
tl following reason:
Z ( ) 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).
( ) 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
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Date Signature of Owner
N
rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
Z () I have and will maintain a certificate of consent to self -insure for workers'
�O compensation, as provided for by Section 3700 of the Labor Code, for the
X W LL. performance of the work for which this permit is issued.
0 J Q () I have and will maintain workers' compensation insurance, as required by
co Q U Section 3700 of the Labor Code, for the performance of the work for which this
O 0 permit is issued. My workers' compensation insurance carrier & policy no. are:
tlLoCarrier Policy No.
Z (This sectio''/need�nofzlie completed if the permit valuatioh4`60'V60.00 or less).
,00 n O () I 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 provision of Section -g700 of the Labor
f: Code, I shall forthwith comply with th rovisio,
Date: Applicant .1
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
V4
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 inspec on purposes
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`Signa�ure..(Owner/Agent) F' / Date3/
Z'1_
I - Y f77
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. BUILDING PERMIT
PERMIT>r
DATE 3/1/96
VALUATION S74.000.00 LOT
TRACT
JOB SITE ADDRESS
APN
OWNER
CONTRACTOR
NACIA)'I•'1'RE POOLS & SPAS
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viiivtiA:r�
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55-S40 MOUNTAIN SHADOW
LA QUANTA CA 92253
LA Qt.1INI-A OA 9225-'1
(f 10 11 A9 -1ril 1 ("IRI 0 10AS
DESIGNER/ENGINEER
(OV�)5644849
USE OF PERMIT
ERMI OOL .ANI,?/Ok SPA
FEE DESCRIPTION
FEES
:1-100t E41*It IOX '.WA 14,000.00 LS
ESSTIXIM -ST t FCO3�1.3I'.6:.Ut:ra"CY T
.14,000.6111
10'9-1000-439.318 399A5
r_'0N',1;°rI2LTcT.10ENTr,mi 101-000-$1M000 $153.00
X41,sC,ftrlNtCAL I Ell •,- P00L 10.1 -000 -42.1 -OW $124100
7
IJ..r+;1 R1CA1,1�EE — .1'T 01.. 101 -000 -420 -OW $45.00
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PI.tdm"].w; r;fs .-- v(:xx 1U 1-000.419-Ui•>{1 $27.00
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0
1
Q
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Su'u-TO i`.,hL CONSTRLIC110N AND PLAN CHECK
$3.48.45
LESS N1..E-PAID .PEES
$0.00
T(Y.1'Ai.PER 1 UT F CES DUE NOW
$348,45
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
steel
POOLS - SPAS
Set Backs
Electric Bond
XK
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles '
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: