9510-109 (BLDG)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
cn
W Section 7000) of Division 3 of the Business and Professionals Code, and my
C)M License is in full force and effect. 1s1
I/ License # ;fT LIc Class_ � ,Exp. Date .,
r• rte, Date ,i! �" C SignatureofContractor r 7� a� /Iia v x�t F:�V✓�J'
(0 H 0)F OWNER -BUILDER DECLARATION
J IU 1 hereby affirm that I am exempt from the Contractor's License Law for the
0_ following reason:
(n ( ) I, as 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 Code).
( ) I am exempt under Section B&P.C. for this reason
�
Date Signature ofOWner
N
O, rn WORKER'S COMPENSATION DECLARATION
aQ 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'
LO H 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.
p J J ( ) I have and will maintain workers' compensation insurance, as required by
D] Q U Section 3700 of the Labor Code, for the performance of the work for which this
O L) permit is issued. My workers' compensation insurance carrier & policy no. are:
'L rn H Carrier NA Policy No. `fA
v Z (This s etion need not be completed if the permit valuation is for $100.00 or less).
co D (certify that in the performance of the work for which this permit is issued,
1 shall not employ any person in any manner so as to become subject to the
g 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,) shll fo�thwito. comply with those provisions.
QWarning: Failure to secure Workers' Comp/t, on 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 informatiorris
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 N)Wner/Agent) Date
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FEE DESCRIPTION
FEES
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1995
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL AAPIRNNOVALS
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)