9602-077 (SFD)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
o Q Lo License is in full force and effect. _J4';N?'y
n W License # a Lic. Class Ekp. Date �!
Date SignatureofContractor r
CA Z r s
(D 0Fl -
a) OWNER -BUILDER DECLARATION
J W I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
cA ( ) 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 SAr:tinn R&P,C, for thio reaao, i
Date Signature of Owner
N
rn WORKER'S COMPENSATION DECLARATION
Q I hereby affirm under penalty of perjury one of the following declarations:
C) Z () I have and will maintain a certificate of consent to self -insure for workers'
�O 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.
0 J J ( ) I have and will maintain workers' compensation insurance, as required by
co 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:
4:LOCarrier Policy No.
Z (This secti_q ,neecingt be completed if the permit valuatiorCiaofgr�$AP9O Q0 or less).
�
:D() I certify that in the performance of the work for which this permit is issued,
C1 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 those provisions. /
Date: l / ' e``y Applicant I � /y
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.
K
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 for Inspection purposes.
Signature (Owner/Ager i a I A Data
5
A`Cx
BUILDING PERMIT PERMIT4A��},QQ%-,
DATE
VALUATION
LOT ` TRACTS"r"y`z
JOB SITE ADDRESS 54-775 W iNGED RIOT
APN 769-4-50-W5
OWNER CONTRACTOR
RAX(l10 GJAPKOUNO Uk VF 1,QF'NI I,
K S L LAND 11 70687C01 iNN_CR.Y i LUR 8` k 0211
56-140 PGA BLVD. R.ik ii,AN,'QtA)A DUNES CA 92201
LA QUINTA, CA 92253
(619) 564-1088 DESIGNERIENGINEER
USE OF PERw1r;Ij4CS : F. I4 IL 1.1 T , 7;(J 1 9!JZ NMKMIL . SC)UTH
I` ° I K OA t6fi i-(NK0....... _..._�..
Al H MM"R 0_JI1F('1 1tJdv 4"' KIIA W1181' f7 �', !
YLAt4 2-13R
FEE DESCRIPTION
FEES
CUSTOM f°ON,1*` 10 PCTION 2.,1790,0t) w3>
1'OR(liPNATIO 202.0" ;3l'
G14ItAG1YC.ART'0!!T 62111W 7?
ESITKATED COST Wi CONSTRUCTION
pti)i2wq. m
P MIT F>�1��� SAINT ,IARY
PT Aliif'tii+(-X VFF 101 S416 1
4'S;1N: A t17 �'I(}lv VIA;' 10111100-418.000 15993.00
ik, (.'NANWALvot s9ia_�)
hLE('URA'AL F�:V, S03.I- 1
P11INMIN'CwFRt^ $1?3�i4
,10 1'438 (• xmurioi4 rw • iws,iu 101-000-241-00 5jl.0-1
0HAOINNU i -El> iflt-Ut)tr 3 -fit) SAW
i 1V1 tilt ;1'I0 TC111t 1`t 1 ktl: f 4_t ?-t31p0- i<b }- 9 a'. rs1,1 D 3 fly
ART I VtA1111 1C too, nf'f`V ,12V0 r. 71)I4 of—1StS{000 so
5U1-TOTtlif, C0NKfPZ.1 M`i0N AND P ,ANI Cr1t 1.1.
81
Q LF.S: 'RIA' 11.1) 011?S
It.(f
PFRAHT FEES DUE NOV;
r FEB 21 1996
I�y
RECEIPT
DATE
BY
DATE FlNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
p
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
ZZ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
f
Drywall - Int. Lath
(�
Final
Final:
POOLS - SPAS
BLOCKWALL
APP OVALS
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
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)