9511-084 (RPL)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.
31 473 B 1/3.1/96
4cense #/ . , ! _.. Lid. Cass /'1 Exp. Date
aW:bV 4//79 Signatureof Contractor
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 construct the project (Sec. 7044 Business & Professionals Code).
O 1 am exempt under SectionC. for thid-re3
%n'3
Date 1 �10 1jr' SignatureofOwner r�-c� {B&� iRA - r"
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of 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 t r .+s.r�+r yg r>'r Policy No. ^ r f
ritt.-Yrr ... r, c�
(This section need not be completed if the permit valuation is o� $100.00 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 shall forthwith comply with those provisions.
Date: 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 •,
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. j
2. Any permit issued as a result of this application becomes null and,void ifJ�/
work is not commenced within 180 days from date of issuance of such
permit,
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 buii�g
construction, and hereby authorize representatives of this City to enter upon`tie
above•mentioned property for inspection purposes.
Signature (Owner/Agent) Data -
"`°'
BUILDING PERMIT
PERMIT�iS�`�
DATE 18116194,
VALUATION S I Z,54i(1.f)9)
LOT
TRACT
JOB SITE ADDRESS • t
APN
a7.795 V NIC1✓
pwNER '-w '
CONTRACTOR
Cr"JRY HOMES C OM1MUN1T ES
CL•h Y 1-1:aMES CCk2'(l�UF0171ES
1.535 SOUTH D STR[3UT 0200
1535 SOi►'rE1 n SIM U1.1 T H200
SAN BERNA RDINO CA 92408
SAN BERN,ARDIN CA 92408
(909)3331-6007 CBL# 2120
DESIGNERIENGINEER
(909X38I-6N 7
USE OFPERMIi%OOL.ANDDIOR SPA
lk.)01, A14D SPA
FEE DESCRIPTION
FEES
POOL ANL)/OR SPA, 12,560.00 LS
1G.MMI AT l!r:l,Ji CO-T.O CONS A RLrMWN
tz.,;00,00
PL A14 CHECK FEE 10.1 •-00() -439318 $93.60
C ONTfRUCTION i~'LR 101.-000-419-(40 $144.00
ME. 1AN[CAL H E'E -- BOOL10.1-000-421.' 000 $24.00
h` X-C17RIC:AL FEW -Pool:, 101-000-42,(000 $45.00
Pi;.irMB.IN EE -,. POOLl(?1-{)00 41�J�01)t3 $V.00
I.
Strt3-'!''�Z°E�.I,.�.!t�.RfS"'TRCJ(."TrrJ.ti7 A�!D!'/:,2p`1Cl??;":s
s?int; PAM EELS
$0.00
.. .:,-LESS
`TQTA1a PERM1T VE9S DUENOW
S333.60
,9 10 ��L P OJEC'T i�:H RMIT F:w WS .
1995
333.600
RECEIPT
[SATE
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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
1,4 4a
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 Eadosure
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
Final
Utility Notice (Perm)
COMMENTS:
�ralSc►0 !'NOTiol 1�-i_T��
',aA_T: _
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TRI LEVE SEA -S U- H GROUiP
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c
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JETS.# 4' I-
M 0 TO P HP STA MAX 2 HR 1 T '
10,+ =1_T=R, SYSTENI.3 30OStiFT
La_ I-_--- '-- - -
- • = 1_T=P. RATE 100 GOV.
1 7LRk(7V.R Z..` HRS
' RETL.RV t WES YES
mil. deck —.
width 3' X 1�' MAN DP,A1N YES
-u^ 4.. �. __►` Iv VER MODEL DUAL PORT '
^`-
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14FATER LSARS SIZE250 060 BTL
1�'D _POOL LIGHT 400 W
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`J r
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ELECTRICAL BCND NG B S.D.G. i
TILE AND I -OMS S.D.C.
I 3ECKING BY S.D.C. SALT FIN -
+0
a XATURAL 6&1 SQF rno STEP
q. 2 K OflNTRA';'OkR cannot 2ss.me l
1 YA 1 wpcnsibility fur da maze to i
-urbs, sidewals, driveAays,
12'3"- ernent s:abs, sewers,
awmi c ees, `ences, retaining'. ;
r I exisri"P ►� walls, spriniders, t.kep o -re. lines
! ® l I _•r shrubs. Wien xc-ss is ma -e
t -rough a neigl-bor's p-ope-ty it s
! ! - mdem:coa t iar- yo.J, tI-e owre-.
_da�r L w - W door' `l' - jI gave that r�egnboes pemi�icn
I and 3ssun-e full. ,
POOL & STA i t ;
a GM18 LltiNTzSWTI {'� S' �,; ' offie_�E-_N - R -Y HOIVW s
47 7 8J „VIA NICE
cov_ LA QUNYYA, CA.
11oBcAT
ACCF..SrBOOM
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b'�
•
� I
�ralSc►0 !'NOTiol 1�-i_T��
',aA_T: _
P.1 .
-ITE 1110 ' I _kt,?_ Bk L: PERIMSE-ER 7iG
TRI LEVE SEA -S U- H GROUiP
]'k 71
S i— :.
`,. 24" i TILE`CCCCR.- CHOICE
• i DAMWALL 'ddIDTi- f a 9' RAI E BEAM 9' OF +6 Vl7 ISE
c
9` PILLWAY'&:ML" X " _O'INo C41\TII.E�'ER &9',
=00_ CAPADT'A 1. SAO GA -S
OPEN .3CLOSES j -UNI: C?.PACfTY 9i1GOP
JETS.# 4' I-
M 0 TO P HP STA MAX 2 HR 1 T '
10,+ =1_T=R, SYSTENI.3 30OStiFT
La_ I-_--- '-- - -
- • = 1_T=P. RATE 100 GOV.
1 7LRk(7V.R Z..` HRS
' RETL.RV t WES YES
mil. deck —.
width 3' X 1�' MAN DP,A1N YES
-u^ 4.. �. __►` Iv VER MODEL DUAL PORT '
^`-
+b� C-1EO( AL VENO Y.
14FATER LSARS SIZE250 060 BTL
1�'D _POOL LIGHT 400 W
A, . 3 \1 E_ SPR LGHT 101 W
`J r
f. _'06'R�+.-_�.—)0'� L'JCK?AI€R2JOV
1 8 ` L-- fir -S`i- _LECTR,ICE" S.D.C. 127'
ELECTRICAL BCND NG B S.D.G. i
TILE AND I -OMS S.D.C.
I 3ECKING BY S.D.C. SALT FIN -
+0
a XATURAL 6&1 SQF rno STEP
q. 2 K OflNTRA';'OkR cannot 2ss.me l
1 YA 1 wpcnsibility fur da maze to i
-urbs, sidewals, driveAays,
12'3"- ernent s:abs, sewers,
awmi c ees, `ences, retaining'. ;
r I exisri"P ►� walls, spriniders, t.kep o -re. lines
! ® l I _•r shrubs. Wien xc-ss is ma -e
t -rough a neigl-bor's p-ope-ty it s
! ! - mdem:coa t iar- yo.J, tI-e owre-.
_da�r L w - W door' `l' - jI gave that r�egnboes pemi�icn
I and 3ssun-e full. ,
POOL & STA i t ;
a GM18 LltiNTzSWTI {'� S' �,; ' offie_�E-_N - R -Y HOIVW s
47 7 8J „VIA NICE
cov_ LA QUNYYA, CA.
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