9511-119 (PAT)LICENSED CONTRACTOR DECLARATION
I 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
Q
In
r- License is in full force and effect. 493919 A B 6/30196
r`W = License # J Lic. Class .. 4 Exp. Date _..^
r a Date ft Z ": Sig natureof Contractor
Z
0 0> OWNER -BUILDER DECLARATION
LLI WCD I hereby affirm that I am exempt from the Contractor's License Law for the
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
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Date Signature of Owner
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OCNJ
rn
U WORKER'S COMPENSATION DECLARATION
Q I hereby affirm under penalty of perjury one of the following declarations:
It d 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
� HO cc 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
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
U permit is issued. My workers' compensation insurance carrier & policy no. are:
LO d rn H Carrier 11, rei AQlZ. Policy No. I'#ACj1QSi 17"
I Z (This section need not be completed if the permit valuation is for $100.00 or less).
00 D( ) I certify that in the performance of the work for which this permit is issued,
r' a I shall not employ any person in any manner so as to become subject to the
F 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, I shalllforthwith comply with those provisions.
Date: ,t!/ l -4— Applicants
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.
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
& 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 laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
•
above-mentioned property f�pe� n pu oses.
^'�'� Signature (Owner/Ag ent)�''4 i ;;;> ' '"�� Daus l
ALC.
BUILDING PERMIT
PERMIT�!,�,14-1-19
3Y�
I
DATE 1,If ,2/1)5
VALUATION :53,436.�C LOT
TRACT Lxt11J
JOB SITE ADDRESS 78-215 =SEK FALL ,SAY
APN
OWNER
CONTRACTOR
CVMIMOS REVEL OPMEW
%4r1L1,W4S DEVE1.01ON-I NT
4266 CAROLINE, G"T. #101
42600 Ct' ROI,1NE ("T. f/101
PA Nd DESBWf CA 92260
PAUL -4 DESERT CA 92260
(019)341-6,380 CBI,# 1.231
(619)341-M- 0
DESIGNERIENGINEER
USE OF PERMIT yAT1,,0
FEE DESCRIPTION
FEES
PORCIVPA:170 108.00 SF
"TMI T.ED COST or CONSTRIUCT ION
I'ERAff ' FEE; SUMMARY
PLAN C.[PFc',:K 1'tM 101-000-439-:3111
CO*ISTRUCTIONFEE 101-00"18-0()0
STONG ]VIO ION PT -Z - IWISID 100-000.241-00()
SLWFOMA.I, CONSTRUCTION AND PLAN CHECK.
$74.75
1,13SS PRC PAfD HES
$0.00
TOTAL Iar+'.RMIT1+ECS DUE NOW
S74.75
TafAL PROJEa T'ERIIMIT T'1rr.C°S
74,75
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
17 Final
Final
POOLS a SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test T
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)