9602-127 (SFD)LIC 'EN i SED,CONTRACTOR DECLARATION.
I hereby affirm that I am liensed under provisions of Chapter9'(commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full rce and effect. ;�' 1
License # Llc CI " s !
j�Date 1. SignatureofContra for �=' �tf
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's: License Law for the
following reason:
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 ths'project (Sec. 7044, Business & Professionals Code).'
() 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 woik`for which this permit is issued.
() I 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 section need not be completed if the permit valuation, is for $100.00 or less).
() I certif�th}af klhgb'performance of the work for which �this 'fpermit tis 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 a wor ers' compensation provisions of'rSection 3700 of the f or
Code, I, sh I fo i comply�I ose pro Isions. P ��
l Date i Applical t /F j ' a�``� /.�
y z r i
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 6f this�appli/cat���agrees to, & shall, indemnity
& hold harmless the City of In�ian Wells,-lts officer's, 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 p rposes. .
'Signature , (Owner/ 4• ent) J 1r�e WM411- Date d� ,� t1
ALC0
BUILDING :.PERMIT
PERMIT'
9602-11127
DATE
7l2:1!'�4i
VALUATION LOT TRACT
$2161:,11439.20 77 2R`749 t°'i3A, :1; 1.
r'
JOB SITE ADDRESS
APN `
5s--,6 's+(Du`6`.%AERN 1113.fla"o
OWNER
CONTRACTOR
ri
36., 1,40 PGA. BL VE). -
i 8MMUDA Dt NES CA.. 02201.
I...E1.t;!t„I.I;N d"f1 Cal, 92 53
? f�i19' :i4ti.7Y55 f"_'nul 'tof;,Q
VDE SIGNERiENGINEER
t61q►'m4-1.(. n
Blif;'I ARE'7-S
6CORKDRKMPAR
USE OF PERMIT, �tlL �.hf: T`l��tile i yJ i S ,.� til
ll(V its, t;A 441 .14
'1`,HE f.l.RI 1'AM C QL14"l', ON - PGA WEST �
P1,AN.V13 ,.. .
FEE DESCRIPTION
FEES... .
c:t is, T c; m Cmuc i -f -N r 2.8-72.00,13F
c JRi Jl Tl4➢/�3.'t(J r e .364.00 S?�
E,
GARAGtCARK)RT { 1177,00 SF
EST MAI'lHal!D COST •0,F t_"+ONSTR1JC' , ON
FERRO #' F EE.4oi)MMA:9S`isr
1?lI:AN C:HURC:: f`1aE 101-000-43'9-31:1
C014STR1.JG`i`I0N.M7 101i0t?0-41"O 51,1316.50
A4 WX ANTGAt, Fts•1s 101-060-421-00
Hv
EL .fR1CAL FFS 10144-420-000 $171.561
Pl,LW03ING .FET 101_000-419-0Q.0 $179.?4
'
S` OINGMCITIONMER.ESID 101-000-241tQ.0 324.1E
..:
GRADING 101-000-40-3-10 .3-20.00
�
3NF"STR.UC:fURE F,E 2.2.5-000-443-342 $5.:332.45,
AR T_ 1N .PMLiC PLACES-1ZESL7' .701-000-2.55-000. $354,60
y
� tr
`y SUB-TarAL CONS1 fi UCT1QN AND PLAN CHECK
$8,2275.73.
,. LESS PU.-PAll.) FEES
$0.00
TOTAL PERMIT FE
193-DUENOW
S8,225.7
�•
RECEIPT ,�"
DATE
BY
DATE RNALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade Z
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 PR
'•`�
VALS
'
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Under round Plbg. Test-
Final
Gas:Piping
PLUMBING APR
VALS '
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 _ZY,
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPR11
10Y
Temp. Power Pole L
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)
LS
COMMENTS: