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LICENSED CONTRACTOR DECLARATION BUILUII
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with DATE .',/ ;jyS VALUATION S10�t4f?t1( LOi
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect.JOB SITE ADDRESS
6561713 C5+ J01311967�•64S DL+".SC:AIYai(D LANELicense # Lic. Class Exp. Date s / OWNER
Date Q- 5_LL SignatureofContractor -74+v� it �1
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
( ) 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
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 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 —Al f r)W Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1 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
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensatiorirprovisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: i,? `s
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, intarest and attorney's fees.
AZAR TARL'C H SEf,BY
'78645 .DE SCANSO LN
LA QUWrA CA 92253
USE OF PERAMPO0 L. AND/OR SPA
POOL ANWOR SPA
i
►512.019
Id:nad
r 646-540-005
CALIFORNIA POOLS & SPAS
41910 BOARDWALK AA.2
PALM DESERT CA 92260
DESIGNER/ENGINEER
10,000.00 I.S
ESTI1VMED COST OF COi�'S7i I2I)C'T9f t
PERINU'T .1+ EE S1J1!"IMARY
PLAN CHEM FIrF
101-000-439-318
$76.05
CONSTRUCTIO14 FE9
101000-418-000
$1.17.00
1VWFLANICAI.. FM -- POOL
101-000-421-000
$24.00
E LF;.G 17RICAL Fk-h -- POOs.
101<OW4204Mf
$45.00
PLUMBING, Fit .- POOL
101-000-4:19-000
$27.00
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 i
& 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 G�
permit, or cessation of work for 180 days will subject permit to cancellatio/'Ir ®c
I Certify that I have read this application and state that the above inion
correct. I agree to comply with all; City, and State laws relating to the
construction, and hereby authorize representatives of this City to enter
above-mentioned property for inspection purposes. :`
� f
Signature (OwnBr/Agent) .+:: t.`• 1 � '/A-'/ %{�-.•..••,,,,,- DAB
SUB -TOTAL CONS'T'RUMON AND PLAN CHECK
LESS PRE -PAID .1" EES
rJ
os 1995
TOTAL :PERAW FRES DUE NOW
INSPECTOR
WX60.Q10
$289.05
$0.00
$289.05
For, Z 1 1:140
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Ale `
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS .
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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 5Z
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)
COMMENTS: