9602-131 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
oWM Section 7000) of Division 3 of the Business and Professionals Code, and my
r-�. Cy to License is in full force and effect.
P- W License # Lic'.``Zs� 49p. Date
ZDate r SignatureofContractor
coo rn OWNER-BUILDER-DE€L'A ATION
J 0 —W (0 I hereby affirm that I am exempt from the Contracto�s7oroffered
d following reason:
(n ( ) I, as owner of the property, or my employees wit
Z compensation, will do the work, and the structure is not ir
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. for this reason
M Date Signature of Owner
LO
N
rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
C) g Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
U-) < O Cc compensation, as provided for by Section 3700 of the Labor Code, for the
X W W performance of the work for which this permit is issued.
0 J J ( ) I have and will maintain workers' compensation insurance, as required by
mQ U Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
CL LO Carrier Policy No.
t Z (this sect16'wh dtt46Kb completed if the permit valuatioE►'is1on$100.00 or less).
r- cy() I certify that in the performance of the work for which this permit is issued,
C'1 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 shall forthwith comply with those provisions.
Date: Applicant
QWarning: 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
v4z4i�)J, 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.
a--""-- '
Signature (Owner/Agent)l/ Date
AL"
BUILDING PERMIT
PERMITS
'i�i112-131
DATE 2/26/104
VALUATION 'E14Y(MI() IM
LOT TRACT
JOB SITE ADDRESS
APN
7XJW SPV+13A%S HILL, DEF.
761.653007
OWNER
CONTRACTOR
J•
I);1'fi VAIAI1''d1'1°W'Ifl�,IN
tl�llstsf+�'
Y Y. IYi Il19'
t�•"+t•r� ,�1't: r,rat>A1 ��'i Ia
Y. I. ri,+Y♦Ia AiYt„., 1Y •C: a.
;1i") SVykA,;kS-S 1111A, hit
t-"tVX1:1t•:[*A1, A 422.0
IA tall ii)rl'I'A ('A u, ti i
I� tu► �ti.. )tst? r' I a
DESIGNER/ENGINEER
1�t ,
USE OF PERMIT,001,
i001. Mill+�ltF,
to x )I. AM) SPA
FEE DESCRIPTION
FEES
Ih.h:N. ANDa xK S11A 14,(Kk1.+10 1,N
>k;STIMATF.0 CL' ST OF CONSTRUC"I ON
14,100.00
PERMITFEE SUMMARY
PIAN ('11EC'K F14- 101 ON) 4W-111 8 l9y.4S
IX1N%'1`)tI)t"TKtNlFIX 1011000-418-0(w SiIS�.tlrt
l4¢X11ANICAL 141 - POOL 101 -000 -421 -OW S24 -ti r
�
ICAJ, I-Wxs --141,)1, 1014N}f1--42Ci-(NNI 545.00
." VI
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PIJIN60NO (IT - K)CC 101 -(X)0 -4W-000 527.00
c.o
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SUI3.1'O1'AL CONSCitIA.'nON AND V1,AV C`11FX'K-
$318. 15
LESS PRE-PIA11i RTS
S0 W
TOTAL PENMIT Ff+,l~;.S 911 IF NOW
S34111.45
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
INSPECTION RECORD .,
V
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL'APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air r
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel G
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 —For
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)