9601-097 (RPL)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business and Professionals Code, and my
=) co License is In full force and effect. f
r- LLICl' License # U& Cless� ! �CEtcp. Date Ii)I iI96
Zn Date l • 1 y` Signatureof Contractor � ''
(0 pr`
OWNER -BUILDER DECLARATION
J Q I hereby affirm that I am exempt from the Contractor's License Law for the
0_ following reason:
En 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
Date Signature of Owner
LON
OU rn WORKER'S COMPENSATION DECLARATION
CL 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'
� H O 11 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
C0 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:
d rn Carrier Policy No.
It Z (This secti6A,ViQd9n t be completed if the permit valuatioAQ`fo'F$1'Obd00 or less).
N o() I certify that in the performance of the work for which this permit is issued,
C3 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' compensation3provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: `" (`7 -,, Applicant ;/y (f✓
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 alliCity, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
• above-mentioned property for inspection urposes.
Signature (Owner/Agent) Dat," -
A"'
BUILDING PERMIT
PERMITS
��tA4 _A?ft7
DATE 111W96
VALUATION S?? �T TRACT
JOB SITE ADDRESS
APN
OWNER
CONTRACTOR
CALIFORNIA POOLS & SPAS
CARDI LL0
419 10 BO ARDIVAI KIM
SAME
PABi DESF.RtT CA 92,26.
1_Q CA 92260
DESIGNER/ENGINEER
USE OF PEAMIT���
FEE DESCRIPTION
FEES
POOL ANWOR SPA 11,(",W LS
ESTIMATED OAST OP tCONS ELE1L"E'EON,
1,1000.00
P-EXIMI T N'f+ E SIJN MAEt.'A'
PLAN CHECK Ff:F 1.01-000-439-318 $81 .90
CONSTRUC111cNN FEE 101-000.41,5.000 $126.00
f �
XtECHAM.IC:AL. FEE._ POOL: 101.000-421-000
ELECTRICAL FEE -- POOL 101-000-420-000 545.00
`.
PLUMB. TNCs.FEF — POOL 101-100419-000 $29.tr0
r
SUES-TOTM, CONTIMUC1<IC:INT ANIS PLAN CH17CK
$303.90
LESS 1'1t -PA[D FEES
$0.00
TOTAL PERMIT FEE S UUP', NOW
$303.90
RECEIPT
DATE
BY
DATE RNALED
INSPECTOR
F -
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
a
Exterior Lath
Drywall - Int. Lath
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain -
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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)