9601-113 (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.
Licens f#, Lic.7dasd %/' 1 A Exp. Date 19/31/95
Date Signatureof Contractor ; 4, n
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).
( ) 4, 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
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
perfo ance of the work for which this permit is issued.
( I have and will maintain. workers' compensation insurance, as required by
Sec ion 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 secti6n1rh4e&A61` be completed if the permit valuatiotAg—for V00.00 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' cbmpen§ation laws.of California, and agree that if 1 should become.
subject to the workers' compensation,proOsions of Section 3700 of the Labor
�
Code, I shall fo with comply with those provisions.
Date: I 1 , a az Applicant i
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
fora 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 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 fol Inspection purposeii
a. {!.
� Signature (Owner/A9ent) �Y . �;a f! � +. � .� .�' Date
ALC'
"' BUILDING
PERMIT
PERMIT*-
9601-113
DATE/&.
VALUATION D4al/1!\➢ hrl
LOT
TRACT
JOB SITE ADDRESS
APN
147-945 VIA. MCE
OWNER
CONTRACTOR
MV E DOT SON COIRTI R.WPION
Cmi`dTuay jIcAw"s COaw.'NmEs
08805A P.FRE,",
051- S .SO rK a grRtrr #7200
f EM413DRAL CITY ' C& fh321
SAN BERN.AR)"i);N, CA 92408
fA101174-17R;j (" kf;-H 1844
DESIGNER/ENGINEER
(909p8j.-mv
USE OF PERMTO OL AND10A, SPA
POOL AN13SPA
FEE DESCRIPTION
FEES
CO1v 1rf, t' A 10UIJ 'T 15,000A VJ :LS
�+:��'.�1i�fi'V`�"t� d,'.��'�` t➢�' �'41QT��"a`ilC'.1f iiL3:�i
1�.�3tid�.Qry
P;Lsl1V CH13, "K F Lffi 101 -000 -43y -.elft $I05,30
C
CONSTRUC°rIONFM. , Iol1 joo'1I8-000 $162:00
WCHANICAr. VVE .o I7c: X, 101-000-421-00a :iso
C rn
'IrfTS:TRIC'.AL FF.,E -- P00U. 101-0t')f24204)00
P1IA1131 IGi Fhf: ML 101-000<41,91000
' SUB -TOTAL CONSTRIX-11011TAIN .i .F'LA CURECK.
'no. VJ
TOTAL' . 9�i '4;4!.,S Y 133 NOW
•.
RECEIPT
DATE
BY
DATE FINALED
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 Wail 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 Z4 14
Underground Plbg. Test
Final
LLGA; Piping
' PLUMBING APPROVALS
1
'GasT6st
'Elotriq,Final {
W ste Lines
-,Heater: Final
Water Piping
;Plumbing Final
Plumbing Top Out
quipment E losure
Shower Pans
,O.K:Yor Finish Plaster
Sewer Lateral
;Pool Cover
Sewer Connection t,
'Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
'
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures - r
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: