9601-042 (BLCK)LICENSED CONTRACTOR DECLARATION
NI hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
.-
LU Section 7000) of Division 3 of the Business and Professionals Code, and my
� 0 License is in full force and effect. 4942.57 Q29 6130/96
n W^ License # Lic. Class� Exp. Date
Z^ Date , , - r ! Signatureof Contractor '! A
( P
co OWNER -BUILDER DECLARATION
J W I 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).
( ) 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
cr) Date Signature of Owner
N
rn WORKER'S COMPENSATION DECLARATION
EL 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'
L OM 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
00 Q U Section 3700 of the Labor Code, for the performance of the work for which this
p U permit is issued. My workers' compensation insurance carrier & policy no. are:
dFQ- Carrier Policy No. ?al;z4mC
I Z (This section need not be completed if the permit valuation is for $100.00 or less).
r- a () I certify that in the performance of the work for which this permit is issued,
I shall not employ,any person in anymanner 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
0 d Code, I shall forthwith comply with those provisions.
Date: - re /Applicant
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 r`
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
LO
& 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 wcrk for 180 days will subject permit to cancellation.
I certify that1°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 purp sex.
Signature (Owner/Agent)'-____2/ Date
ALCM
BUILDING
PERMIT
PERMIT 0601-042
DATE 1111,/96
VALUATION sz,%0.4%
LOT
TRACT
JOB SITE ADDRESS 78-715 1A PALMA
APN 604-172-009
OWNER
CONTRACTOR
TON4 STONE MASONRY
RICHARD F & SHARON L01100
52637AV D;TDA \ 13A.A.
78715 LAPALMA Dk
LA Qt.%WA CA 92253
{A. CaU11<I1'.t1, C A 92253
t61.9)SG4212S CBL# 1.228
DESIGNER/ENGINEER
USE OPPERM ITj1iN.1,RAI, f7f..,1ITUDINKJ
IOtY x 6' 04,(XI'K. 0AR1.'21 W WAIA-i
FEE DESCRIPTION
FEES
6F'!. WtAiL 100.4) LP
W`O"j ED COSH OF CONST -RUCTION
1,500.00
1°FI1l.MIT .i+1+...E SUMMARY
• CONS°I'.ELUG`7.'MON QEF 10.1w00("18.0(K) 5.54.00
%® say . L :-ci s RWPION D PLAN CH6CX
$54.00
J4A( USS FRE -Feta P
1$0.00
11 19 TOTAL PEJUMIT EES DUE NOW
x54.00
y
RECEIPT
DATEBY
. a
DATE FlNALEO
INSPECTOR
s
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
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 APPOOVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam rzApproval
to Cover
17 OK ev Z-0
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
.
PLUMBING AP ROVALS
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
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: