9601-120 (BLCK)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
License s n full aneffect.
O � Liiifll fd
591684 2'_� 413(i/gt
r` w r License Lic. Class f Exp-.ryD�ate
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(D � OWNER -BUILDER DECLARATION
J IU I hereby affirm that I am exempt from the Contractor's License Law for the
W LU following reason:
~ U) () 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
N
rn WORKER'S COMPENSATION DECLARATION
dQ I hereby affirm under penalty of perjury one of the following declarations: 4
Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
LO H 0 compensation, as provided for by Section 3700 of the Labor Code,.fo-r the:
X w LL perfo7ance of the work for which this permit is issued.
Q J J (i) 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:
4: H Carrier ora";_ t ::;: ; Policy No.
z (This section need not be completed if the permit valuation is for $100.00 or less).
�
Z)() I certify that in the performance of the work for which this permit is issued,
O 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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Data//,s?03e /,_ 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
0 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 Vold 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 authorise representatives of this City to enter upon the
• aliove-mentioned property for inspection pu}poses.
Signature (Owner/Agent). f ae ars
A"'
BUILDING PERMIT
S
PERMIT9611111.120
DATE In.M6
VALUATION �,.A401I
LLOT TRACT
JOB SITE ADDRESS
APN
7-9-240 MANE,��
OWNER
CONTRACTOR
HJXMI:.TON MASONRY .
JOtTN RU8,10
P.O. BOX 1771
i9-240 DIANE DR
LAt IlFIV's`'A CA 9225
LA. QUINTA CA 92253
01.9)345_ 659 t :HLA J.631
DESIGNERIENGINEER
36"120
USE OF PERNL'rN.1s+2:A.L ff(JILI).iNCi
901..1: 4' GARDEN WALL
" FEE DESCRIPTION
FEES
_ 4 Fr.'WALL 9u.t10 Lf`
.i
`
r`F M SVA PP' zre' ,
A.. rtrha•B' IK"
il.ilA..�4.D.�Q ili+ �'c'�'Tw�S�K�.iil:.:e.ft.�i�
' e wit 1
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PERMIT 'hEESC11!!1NrlAi Y
C:'0IdS'.YR1JC T1 N FES 1O1AX10-419-(:1)O $35.00
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GAJ
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SUB -TOTAL CONSWRIJUrIG14 ANL3 PLAN C14ECH:
S35.00
LESS .IRP.-PA11) FEES
$0.00
'9'OTAI., PE RI IIT :i+'CES DUENOW
RECEIPT
DATE
BY
DATE RNALED
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
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APP OVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain.
Bond Beam
JX
Approval to Cover
17 11
Equipment Location
Underground Electric
on
4
Underground Pibg. Test
FinalGas
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
r Final
Utility Notice (Perm)
COMMENTS: