9601-102 (PAT)cA LICENSED CONTRACTOR DECLARATION
N 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r � Section 7000) of Division 3 of the Business and Professionals "Code, and my
o =c.) License is in full force and effect.
n W j L' ense # U . lasso Exp. Date
rZ N ;pate Signatureof Contractor
0 r`
02 OWNER -BUILDER DECLARATION
J GO I hereby affirm that I am exempt from the Contractor's License Law for the
a.
W following reason:
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
Cl)
Date Signature of Owner
N
WORKER'S COMPENSATION DECLARATION
0_ Q I hereby affirm under penalty of perjury one of the following declarations:
C) g Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
r H Oir compensation, as provided for by Section 3700 of the Labor Code, for the
X LLI 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
p 1J permit is issued. My workers' compensation insurance carrier & policy no. are:
a u) Carrier Policy No.
? Z (This section need not be completed if the permit valuation is for $100.00 or less).
00 Cy () I.certify that in the performance of the work for which this permit is issued,
I shall/not employ any pdrson in any manner so as to become subject to the
workerscompensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Cade, I shall forthwith comply with those provisions.
(gate: 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, 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
& 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
• abeve.mentioned property for. inspection purposes.
'S�gnetiJre (G"/Agent) Date
ALC '
BUILDING PERMIT
PERMIT•
9tifl3-.1t3�
DATE 1113196
VALUATION S151519.51
LOT TRACT
JOB SITE ADDRESS
APN
50075 WRALTf'
OWNER
CONTRACTOR
NUM�q GOhi`T3CJ'liJ�3
7 .' N WAi k'ft3�t,i"
s0 # iL%4ANJAR0 Cr,
SAME
PALM DESERT CAS 422.11
LCA
t t,1 �� x:45-i99R C'ii
DESIGNER/ENGINEER
USE OF PERMI
FEE DESCRIPTION
FEES
4-10RCHfi.>ATTO 415,00 S1'
VVUMA'1C ,Z COST Or CONS`i'IR><1MON
5,519.50
11'ERi9.l'l; FFI,, SUMMARY
Tff,AN CHECK F—FE 101-000-439-2118 552.0
t ONIS`p°RUIZ VON M 101-000-418-000 $81.00
G ON ; i1 OTION FEE - R01D 100-00().•24=-000 5.53
4
A:'U13-T J AL NSTRUM'1�1N ,AN) PLAN CHECle.
SO4 20
i [.ESS PRE-PAU)I :C ES
o
"$000
FEB 15 1996
TALC Rik RMIT :E+ E S DV E NOW $134.20
BY
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 Wall 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final:
Utility Notice (Perm)
COMMENTS:
a]