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9512-061 (RR)LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with W Section 7000) of Division 3 of the Business and Professionals Code, and my C:) ^ � License is in full force and effect. 6731>16 C:39 x}/95 r- W cense # Lic. Class Date Cc: Z n Date I I ' `t f Signature of Contractor Y (D F OWNER -BUILDER DECLARATION W 1 hereby affirm that I am exempt from the Contractor's License Law for the CL following reason: U) ( ) 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 C0 Date Signature of Owner LON OU rn WORKER'S COMPENSATION DECLARATION a 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' uu) cc 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 -3 ( ) I have and will maintain workers' compensation insurance, as required by m Q 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: dLOCarrier .RIIA't7 F (Thin Policy No. ?RS9i Z (This section need not be completed if the permit valuation is for $100.00 or less). OD � () I certify 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 g workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of iSection 3700 of the Labor ` Code, I shall forthwith comply with those provisions! �. pate: Ib 1 - 7 Applicant VA" 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 44 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't."' & 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 lawsselating to the building construction, and hereby authorize representatives of this City to enter upon the • above-mentioned property for, inspection purposes. Signature (Owner/Agerrt) / .w �w.!'�\ Date All . ALC 9 BUILDING PERMIT PERMITS DATE 1111 ;J9.i VALUATION 64,476.114JI LOT TRACT JOB SITE ADDRESS 78-600 AVE. E. LA FONDA APN OWNER, CONTRACTOR JAitCIILAC10 DAVE & VEVA aivGE 54180,AVE. YEaASiO SAAIE Ltd QUINTA CA 92253 LA QiJiNTA (:A 9.2253 (619)564-3511 CBIJI 3021. DESIGNER/ENGINEER �+ USE OF PERMIT"yF NFRA= IrUILD.iNG FEE DESCRIPTION FEES CONfR.ACT AMOUNT 4,476.00 LS F,STIMi TED COST OF CONSTRUCTJON 4,476.00 PIE RA!I IT FEESUMMARY REROO FM 101.000-418-000 $30.00 i i StN-TOTAL COiJS`"i` WC' 101 AND PLAN CHECK $30.04 7* : LESS 1>'tZ;E-PA[D PRES $0.00 --�1 OTAL PE10111' FCES 0 UFN08V $30.00 SEC 1 1995 - RECEIPYJ E FINALED INSPECTOR 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 /2 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 APPROV LS 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: �/QT �/�' ` ' ell 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)