9511-022 (PAT)s
LICENSED CONTRACTOR DECLARATION -
N I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Profession nls Code, and my
Oc?) License is In full force and effect. 61113 61 xs x.2,'2'95
t; W ^ /License Lic. Clas A Exp. Qate
Zr Date/" " ! Signatureof Contractor ;3,--.�.-�•y
O I` I
cfl H rn OWNER-BUIL',DEQ DECLARATION
.0 (0 1 hereby affirm that I am exempt Wom the Contractor's License Law for the
w d following reason:
~ U) ( ) 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).
( ) 1, 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
LO Date Signatureof Owner
N
UO rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
Z 1 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
X W LL. performance of the work for which this permit is issued.
O J J () I have and will maintain workers' compensation insurance, as required by
m Q j Section 3700 of the Labor Code, for the performance of the work for which this
O C) permit is issued. M workers' compensation inscarrier & policy no. are:
CL rn H Carrier FRIP!iON1) insurance COMP Policy No. W 9459344901
'I Z (This section need not be completed if the permit valuation is for $100.00 or less).
r- a () 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
g workers' compensation laws of California, and agr" that4if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shallrfo w comply with those provisions
,.,.ate:—�f �r2 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.
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 alIcaCity, and State"laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
• above-mentioned property for inspection purposes.
%Signature (Owner/AgertO'`"
f
ALCM
�"
-BUILDING
PERMIT
PERMITti���-"��
DATE "'"'
VALUATION"'``'`'b 7=T
TRACT
JOB SITE ADDRESS 5j"65 (;i';W,4J)' i{AVJ,7 i
APN
OWNER
CONTRACTOR
A YERS OROUP
355 BRI. I. ST. #A
.355 RIUSML ST. WA
COSTA M a"A CA 9626
COSTA NIP. SA CA 92626
(714)540-6060 C8L## 3374
(714)540-Ch0Et1
DESIGNER/ENGINEER
USE OF PERMIT) '.[Y It UV l Mel
EN RLY PORCH PLAN 2
FEE DESCRIPTION
AFEES
PORCWPA IO 92.00 3F
ES'6 URAU:D COST OF Ci➢NS:iRU:tC-7T
>I,2�3.6i3
PERMIT YCE SUMMARY
PLAN CRE, K. FEC- 101-000-439-31.8 $29.25
CONS '}:f1UCTfONFEE 101.-000.418.000. V5100
STOKG MOTION FTT- - .(ESr, 100-000.241-000 $.:50
`A
w
SM -TOTAL CONSTRUCTION' AND PLAN CHI-3CK
$74.75
.GESS PIZE-PAi'! � FEES
$0.00
TOTAL 3'ERM11 !"EF.S DUE NOW
$74.75
TO-TAL PROJECT PER.MIT FEES
74.75
RECEIPT
DATE
BY
DA7�.,
N�% q
INSPECTOR
s
r
INSPECTION RECORD
OPERATION
T 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,
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 Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
I Pool Cover
COMMENTS;
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)
t