9602-062 (RPL)LICENSED CONTRACTOR DECLARATION
N I h� reby affirm that I am licensed under provisions of Chapter 9 (commencing with
C) W M Section 7000) of Division 3 of the Business and Professionals Code, and my
n Q License is in full force and effect. 2.M947 C53 3131/96
r- W ^ License # E Lic. Class . Date
r, ccr- ate - ,r K SignatureofContractor `
Z r-
0 V w
coo 6 OWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
0_ following reason:
Z ( ) 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
N
O rn WORKER'S COMPENSATION DECLARATION
aQ I hereby affirm under penalty of perjury one of the following declarations:
'a' � 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 W performance 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
O0 permit is issued. My workers' compensation insurance carrier & policy no. are:
CL LOCarrier %�liLTa1 N T A%�l.T; Policy No.
? (This section need not be completed if the permit valuation is for $100.00 or less).
00
() 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' compensationprovisions of Section 3700 of the Labor
Code, I s all f rthwith comply withse rovi 'ins.
Date: Applicant
JI
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.
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 r resentatives of this City to enter upon the
• above-mentioned propeyo insp oses.
S��re (Owner/Agent) + Date�// '
ALC x
BUILDING
PERMIT
PERMIT1",-,,
iiMM
DATE U
VALUATION ..0 ' A
LOT
TRACT
JOB SITE ADDRESS 44-680 F ON'I 1 RRA DR
APN
OWNER
CONTRACTO[Rr�
{� r�
MAS /'E R FOOT S
JORDA14
'173555 1 INVY 111
44-680 FONIIERRA DR
PALi I DESFRT CA .42260
LA QUINCA CA 9225:3
(610)346-6115 CBL# 16
DESIGNERIENGINEER
USE OF PERMI0A Jt; t\ V UiU'ti, a rtt
POOL &SPA ONLY
FEE DESCRIPTION
FEES
POOL ANDIOR SPA 12,0W.0Q ,U;
WiTItME1TED COST SOF CGINS-i'itvCJIGN
12,000.00
PERMIT FEE 3i1JWM.a11 Y
PLAN CHECK F33E 1(114110-419-311 $87.75
(10 is r ur�rION FEE 101-000.418-000 a135.00
MECHANICAL 3TE —POOL 101.-000-421«000 524.00
1 LE(:1'R1CAL FEE -- K-X)L 101-(1)0.420-000 $45.00
PLf.i'M BTNGYUE - POOL 1.01-000-4,13-000 $27.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -:PAID FEES
$314.75
$0.00
U 'SOT I, PERMIT FEES DUE NOW
53111.7;5
RECEIPT Y
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
IV
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 Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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