9601-021 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect.
License # Lic. Class Exp. Date
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
followi�r g, reason:
( A/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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code).
() I #rn exempt under Section , f,. B&P. . for this?reason
Signature of Owner 1� I _itU^
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 work 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.
(ThiVsec on need not be completed if the permit valuation is for $100.00 or less).
rtify 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 Section 3700 of the Labor
Code, I sh I forthwith comply with those pr • visions.
Date: Applicant�!��} 1 a�J4i
K
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
& 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
. propertfotr inspection purposes.
_Sq'r ure (Owner/A9ent)ri
Q}A Da6s�_'
ALC0
BUILDING PERMIT
PERMIT#
DATE J/ &96
VALUATION ,�; � U, 6 LOT TRACT
JOB SITE ADDRESS 4"57 VIA "IST"
APN 646-122-006
OWNER
CONTRACTOR
OWNER/13I.T[.L,DER
JAMES Rt MSEY
48557 VLA AMISTAD
LA QUINTA CA 92253
Cull#
DESIGNEWENGINEER
USE OF PERMIJ.) r1i
T TtEM YAW), AND 3' SID YAW SlrWACK RO)IJOTION APPROVE PM4 BA %-350.
FEE DESCRIPTION
FEES
L'ORCWPATIO 4(K).00 8
ESTIMATED COST OF CONSTRUCTION
5.320,00
PIS{:ILMI"[' k'E( .SUMMARY
PLAN CHECK. FIE 1.01 -ON -439-31.8 :$52.65
CONSTRUCPYONFEE, 101-000-418-000 $81.00
STONG i1WHON FEE - RESI) 100.000-241-000 S.53
SLID -TOTAL CONS'nIUCT1ON AND PLAN CHECK
LESS PU-PAID FEES
$131.25
$0.00
TAI. PERMIT FEES DUE (COSY
SAN � 5 1996
$134.18>I
13,v
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
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 U
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 P OVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
COMMENTS:
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)
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LAGU[
1)E I.A 1'A%
ARCHITECTURAL VARIANCE REQUEST
Unit 1 Date
Street Address 40
Local Phone 77/- •332 O Dther Phone
To the. Architectural Committee:.
we, the.undersigned owners,. 'request your approval of the
modifications proposed on the reverse side of this form.
Att-ached are drawings of the work to be do-ne.; types of
material to be used are indicated on the drawings. We
understand that building. permits for home improvements are
required by the City of "a Quinta and that the cost of ';he
permits and responsibility of obtaining:permIts and
subsequent inspections will be borne by *us..
we ack.owledge that all approved 'changes in .the original
design will be At our expense; that any damage to or
relocation of existing sprinkler systems,'underground
utilities; building* structure and exterior landscaping or
other damage resulting from construction -of these permitted
Improvements will be at our expense; .'and that maintenance of
` the permitted improvements will be at our expense.-
Signature of all owners:
V
' r I �L,40�_�
Please przvide as much detail as possible so that the
Committee may consider approval without de'_ay!
o /h /a Te
The above proposal has been reviewed by the Architectural
Committee and has been:
APPROVEDREZECT_D O P:YOING FURTHER
- a INFORMATION O
Comments:
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