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9601-105 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby rz firm 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 on = � License is in full force and effect. 0 y - O oe -1,v c2e, 9/30 5 n W ^ License # Lic. Class J Exp. Date Zn Date 5- Signatureof Contractor CTD OWNER -BUILDER DECLARATION ! J W 1 hereby affirm that I am exempt from the Contractor's License Law for the W a following reason: ~ (n ( ) 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 Section B&P.C. for this reason M Date Signature of Owner N 0 rn WORKER'S COMPENSATION DECLARATION CL Q I hereby affirm under penalty of perjury one of the following declarations: Z () I have and will maintain a certificate of consent to self -insure for workers' uu) WO compensation, as provided for by Section 3700 of the Labor Code, for the X W ILLperformance of the work for which this permit is issued. •- p J J ( ) I have and will maintain workers' compensation insurance, as required by m Q U Section 3700 of the Labor Code, for the performance of the work for which this p U permit is issued. My workers' compensation insurance carrier & policy no. are: d rn � Carrier py;..[img1,Tr. l'T417 Policy No. 24ki^v?y? I Z (This section need not be completed if the permit valuation is for $100.00 or less). 00 :D ( ) I certify that in the performance of the work for which this permit is issued, o 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/provid! ns.----�-^ NDate: ,9�lp Applicant Warning: Failure to secure Workers' Compensatior(covera� unlawful and shall subject an employer to criminal penalties and civit-fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application agrees to, & shall, indemnify & hold harmless the City of Indian Wells, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if/ work is not commenced within 180 days from date of issuance of su permit, or cessation of work for 180 days will subject permit to canceliatipp I certify that I have read this application and state that the above informabbbVis correct. I agree to comply with all City, and State laws relating to.ttie buil construction, and hereby authorize representatives of this City tornter upon the • above•mentioned'propertyrforinspection urpose6 y}�' ! y ` -,Signature (Owner/Agent) Dale ”"i I BUILDING PERMIT INERMIT: DATE 1/2206 1 VALUATION S'(-y4ft,()(j LOT I TRACT 1 79-150 CALLE r t` R UNA I. 769-104-002 1 U11..;1.PAP11:10 cb'P1ESSI ? :LYON 78150 CALLE FOR i LINA LA Q1 INrA CA 517253 (0 ) USE OFPERMIL, 'N,,I s'3if11..T?$i4`G 11 5.L..F. OF 4' HI01`t f Aidl. EN 13,t.X,34r'[s' WALL, 4 FT. WALL R.0 3F,R:1'Tti.'f..0 t rMASORRY 4=0 Bt-'e",.COM i;I',t. #A P.t LI.1 DESERT CA 92260 (,619)773-0012 CBL# 1244') DESIGNER/ENGINEER 115.00 Z.1, E-IMMIXI"N'r, C051* OF CWTSTRIUC113.01V i'E4`i.MIT 1t C.1j,,4(JMJMAH COI\I STRUCT .ION .FEE 101-000-418-000 543.00 RECEIPT s1.�T3-Tf�'TAL COINTSr'.T'i3.UC"F ON iZND PL. AW CHECK 'TOTAL PERMIT is E 1K5 DUE NOW TE FINALED I INSPECTOR a;a%c��D.£i13 $1,i Q° 00 $aoo $43.00 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 POOLS - SPAS steel Set Backs Electric Bond Footings J a Main Drain Bond Beam G Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final , Gas Piping PLUMBING APPROVA S 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 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: nnA .,j STATE LIC. 0629176' ROBERT TAYLOR COMPANY MASONRY CONTRACTOR 42-200 BEACON HILL, SUITE A PALM DESERT, CA 92211 BUS.: (619) 773-0012 o FAX: (619) 776-1640 STATE LIC. 0629176 ©wN�R LyoNs . 78 -15-0 FOe-TVMA IA Quff4rAl c4_ r/7 P 'Tt en/