9601-111 (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. i�ilii:, f43ia��y
License # . Lic. Class, Exp. Data ✓ p �.---
Date •, SignatureofContractor.7 X p
r 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).
( ) 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.
( 4I 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 ii XI M, A )141:a Policy No. 12i2ti 7", 1
(This section need not be completed if the permit valuation is for $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 withffiose provisions. F ^�
Date: t/, 1w A 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, damage: as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Direotor of Building and Safety
for a permit subject to the conditions and restrictions st' forth on his application.
1. Each person upon whose behalf this application is mac.., & each person at
whose request and for whose benefit work is performed una ;,r 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 'nployee&
2. Any permit issued as a result of this application becomes null 6l.1 void if
work is not commenced within 180 days from date of issuance m' such
permit, or cessation of work for 180 days will subject permit to cancella;Ion.
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 pufposes:
Signature (Owner/Agent) 1/�`�',✓ ,� Date �f/��_ikZ.
7
A"'
BUILDING PERMIT
PERMIT�I�_><><>i
DATE f/Z1/`-b
VALUATION 1Je�f�f1'.tltl
LOT
TRACT
JOB SITE ADDRESS 47-SJ4 f V to MCF,
APN
I
O NER
CONTRACTOR
ISr17Vr, 00011-110N, (110N�CRtTC710N,
(MWA }' 11ttE RR ftE-9
s 5 - a Sol 'Ira ;r 9ME1,11 4200
tE'A111f:lAUL CMY CA 92234
SAN Ii NAR'1 IN- CA 92409
Wlt)0'11 -1232 (AtL11 'rua I
1000)3 t) � 110 i
DESIGNER/ENGINEER
USE OF PERMIVa j'(11, r1i+i.U,'O i NVA,
PO( 1. ANN 811A
FEE DESCRIPTION
FEES
4. ON iAt AG t A1ci.QU1 7' 13A0).W LS
UST MATE'D GIST OV Ci NS' RUC"iION
.r► it ii
PERMIT 14% 341MIN4A.RV
PLAN CHECK K F'£19 1101.000.439-319 $105.30
r-r)NISt'IRL'-0'1`I2''1\rhL IDI P-9.1&{) OCO
W..trti.t�i?
1�.tI`�lr�•/>.1,1 E __ V( iL 101-000-421-000 Sr t,tha
� 6
1A,F:C"1R1CAf,.1'1k-- POOL 10t_0()U-410_000 S45.00
C+,
PI.tTRfF4t'PFO FEF --. P0011 101 -MID -4.19-000 SZ7.00
C\2
7
SUB -TOTAL CONIS' Ir -TION AND PLANT CHECK.
S30 N1
LF'SN PRE -PAID F'EE'S
$0,00
TOTAL PCRI IT FFFS VUE I ONY
5363.30
RECEIPT DATE BY DATE FINALED•c 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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SFAS
114
Set Backs
Electric Bond
71,14, -4111
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
jV1 70
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
All"1
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
En psulation
/
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:
F LA, QUINTA, I������
SAFETY DEP 4;
a �`ARTMENT .- ray'.. W'Ur4 -OPINC �y
L w �,�/ . Pt -HAY ija' :i " l Csf'r� COLOR
�.
CONDITIONALLY "U� ' " SP!L—W-°,} POOL CApar7Ty- _ oJ�!S
ACCEPTED FORaCONSTRUCTION. 1 /
V 1 ', u+'JT04
SUBJECT\O INSTALLATION AS PER #= ' �r_� 7A
SUCTION LrE S
AN ALL APPLICABLE CODES --- _ 15 1 _ � ,RM LNE-s
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