9602-083 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professionals Code, and my
License.is in full force and effect. 597975 i3 f '%/31196 /
License # % Lic. ClassExp'. ,, Date / a� f
<.-
Date Signature ofContractof"N'•',M)1l "' //lZeV///,,
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 coristruct'the project (Sec. 7044, Business & Professionals Code).
( ) 'I am exempt under Section ' , B&RtC-for this reason
Date Signature of Ownerw
' WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintajn a certificate of consent to self -insure for workers'
compensation, as provided�forby Section 37,"OQ!f 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 Policy No.
(This sectignln,dlrZo l e'completed if the permit valuationys f% $300;00 or less).
() I 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' compensation provisions of Section` 3700 of the Labor
Code, I shat fo lith comply wi those provision
ons. �.�,�✓'
�j�! PY P
Date: 1 ;i."/ ///,Applicant. /�sdi✓ :l
Warning: Failu'reto 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 8 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 IndlanMialls fits officers, agents and employees.
2. Any permit issued as a result of 4Fiis 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,re re-sentatives of this City to enter upon the
above-mentioned property for inspeon; purposes. l
Signature (OwnedAgent) ;M/ ,`� lt11,41ff� Date
r'
r'
ALC M.A .
m.a-BUILDING PERMIT
PERMIT.#�a����
DATE `'' " "`
VALUATION " }ovb""
LOT
TRACT
JOB SITE ADDRESS c&4_655
APN
OWNER
CONTRACTOR
kANCliO CAPISIW,'N'O D VELOPt i.: 1 .
RANCHO CAP .ISTIIANO DEVt;:1,OI M-1
79687 COLLA iRY CLUB DR 920 . -
'1968'7 COUNIRY CLUB DIP, ti20
BERMUDA DUNES CA 92201
R£ IZ.1btl' DA DUNT IE: 'CA 92201
,4 196
(61.9)345-7755 C011.14:9
(619)345-7755
DESIGNERIENGINEER
CYP rrs'f'>: NATIONAL
).7992 Ib11TCNELL SOUTH
PERMIT>
USE [Vu'iL "iilV uv<i'
f'k'11"):NTP_ CA. OW(i50-0470 .
TkR RYD:ER COl,I.K: ION AT PGA Wlrs'r PmAm t
PLAN 3 -CR r
FEE DESCRIPTION
FEES
CUS 1701M CONST3RU(,"'f'fON . 2,431'1.00 SF
PORCH1P6 TIO 245.00 SF
C ARAMICARPORT 537M M S' ,
ESTITM iTEDD COST OF CON:STRt1C'." g ON
204,442.711
PERMIT F1! E' S><T.134.MARY
WAN Cl-IJE : FW, 1.01-000-439, 318 SM.27
CON'STRLJ`G"i` ONFE-E iOl-NO-4187000
MIPMAMCAL FEE I01-000-421-000 $92.00
EJ,EC:'f RJCA1L FFA 101-000420-000 S15-+.79
PILUMBING rKEF, 101-000- 51,015
STONG NIOT.l(iN FEE - RUSID 101-000-241'-000 $20.44
ORADIWOFEE 101-0-00-423-UGO
11WRASTRUC.TU th FER 225-000443-342 $4.526:64
ART fN PTJBLI.0 lir A -CES - RUSM 701-000-255-000 $261.11
r
D SIJB.-TOTAL CC 7RUCTION ANDPLAN LAN C.HEC.1
$7 011.50
FEB2.1 1996. LESS PRE-.11AID RES
$0.00
t
COT.. i1 Ci RMIT:1t'US DUE NOW
$7jV71.'M) .
.RECEIPT
DATE ]BY
DATE RNALED
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 IZ6Vents
Fireplace P.L. L
Grills
Fireplace T.O. ,r
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 I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out 1011,
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral z
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
Final 764.
Utility Notice (Perm)
COMMENTS: