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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. 6i31ti1 n '�LafyJ
License # Lic. Class Exp. Date
Date elSignatureof Contractor
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 Signatureof Owner
� q
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
performance of the work for which this permit is issued.
( ) I 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. we:
Carrier FR24014000MP Policy No. WN9459-1t4-V1.
(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 with those provisions.
Date: 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 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 purposes. J
Signature (Omw/Agent) I 1 4 �'l Date
\I)i %17—
ALC #
AL" .�._..._._� __-BUILDING PERMIT 4IPwRMIT4S]0-070
JOB SITE ADDRESS 54-K5 GiWQ TRAVERSE
RSE
OWNER
FAIRWAYS LA QUINT.A.
50-525 GRAND TRS' IVERSE
LA QUA? Tlk C.A. 92253
USE OF PERMITi .IVIG r . ;.ArVi.11. Y U EL 1NU
NIOD1 L PLAN 3
FEE DESCRIPT
CUSTOM TOM COPNSTRUCTTON
C"iARA0FJCAR1; RT
TRACT
A.1 EPS � ei2C1fi_f('
355 13R15.i'OL S; . MA
C091'A MESA
(71.4)540-6060CUP 3324
CA 92626
DESIGNERIENGINEER
F.RMK MMZALES & ASSOC.
1336 FAST CHAPNIAN
014-W LF
1-180) 8F
484.00 GF
1995
5 90.1
$0.00
t
TQTAL PERMIT FFMS DUE NOW 1 $5.890.15
T 0M, FROM, C 1 PFRt'vg1 T yF rL1h,.S 1 .591890.12
DATE 1BY IDATEFINALED IINSPECTOR
918kl IT FCC `UMMAHY
PLAT CHEXX FBE
101-000-435-318
C0NSTRUC.'71ONI-hE
101-000-4113-000
SE�t31.t10
LVIECiiA141CAl. Fisr
101-000-1121.OW
W-50
OX.C"I'R.ICAL FCC,
101-OOU 20-000
$143.67
i'1.Ctf\fl131tC3 F,F"t3
1.01-000410-000
S10.60
S'TONG MOTIONT FEE - RESln
GRAD LNG, FOR
100-000-741000
101-GOi 423-000
526.E
$20
lNtaliASTltl1C •,1'UkZF f•TE
i2.5.01K3-443- 4Z
D 53.T ...
ART TNTIUB .1C PLACES 70P -d300-255-000
5130.53
OCT 2
B
SUB -TOTAL CONSTRUC1'M AN'ti
PLAN Cl M
LESS 'lUi-PAID FEES
1995
5 90.1
$0.00
t
TQTAL PERMIT FFMS DUE NOW 1 $5.890.15
T 0M, FROM, C 1 PFRt'vg1 T yF rL1h,.S 1 .591890.12
DATE 1BY IDATEFINALED IINSPECTOR
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
POOLS - SPAS Y
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
Pool Cover
Sewer Connection ;
Encapsulation
Gas Piping
Gas Test
Appliances
Final
p
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
:1
Temp: Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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