9512-113 (SFD);? 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. 1,979975 13 111196
License # Lic. Class Exp. Date
Date.L Sig natureof Contractor Z.
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 370Q, of the Labor Code, for the
performance of the work for which this permit is issued.
Nf 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. are:
Carrier Policy No.
Mis sectldii/0edXcAo b® completed if the permit valuatiol"i. Wforl$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 p rposes.
Signature (Owner/Ager `C,.:; Date 12 ze 4�
ALC >r
BUILDING PERMIT
PERMITS
Jsxz.xx3
DATE 1414MY1
VALUATION JJ
TRACT c?S116
JOB SITE ADDRESS 80-196 HERMITAGE RMITAGE
APN 761-47(6-035
OWNER
CONTRACTOR
RANCHO CAPISTRAN TO DF.VFLOP
KSL LAND
79687 COUNTkY CLUB D1t 1#20
56-140 PGA -BLVD. t
BERMUDA DUNES CA 92201
LAQUINTA CA 92.253
(619)345-7755 CBL# 1969
DESIGNER/ENGINEER
B B Ci A,RCWTEC1'9
26 CORPORNI'i: PARK
USE OF PERMIT)IINi a ',NTv 1 i 1.% v i Ltd C,r
IRVII'tiR CA 92714
PGA WHS'T - THE MASITA13 COLLECTION PHASE I
FLAN ..2 A.
FEE DESCRIPTION
FEES
CUSTOM ()NSTRU( TION 4,2:50.00 LF
PORCH/PATIO 790.00 %F
GARA4UCnRPOW11 713.00 SP
IESTINIATED COST OF CONSTRUCTION
3.55,556.80
PEWIT FEE SUlYiAtARY
PLAN affl,.CR.'FW3 101-000-439-318 $.1,249.64'
� -
0014STRUCTION FEC 131-000-418-000 51,535.5+
--
WCHANNICAL FEE 101 -OW -421-000 S143,k50
—� !
EL F/_' `RxCAL FEE 101-000-420-000 $23%51
,PL.U1N_BINO'Fai 101-000-419-000 $224.00
Ln
L� rn
S'TOrIO )MOTION Tm RESID 100-000-241•-000 $35.56
,—
CIRADINO ,1M 101-000-423-" $20.00
Go
INFRASTRUCTURE Fa 225-000-443-342 �,ocn,,o�
PRECISE PLAN 1.61-000-44.1.-34 d " $25.00
ar Q
l
ART 1N PUBLIC PLAC T -S - I1ESIC 701-000-255.000 Wf".38.89
LLJ
�
[Y°
SUB-10TA.L, CONSTRUCTION AND PLAN CIIEC.1C.
$10,111.1+0
.LESS PRF -PAID FEES
$0.00
TOTAL PTRM..ffFEES DUE NOW
5�13,,ill.fill
RECEIPT
DATE
By
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
•MECHANICAL APPROVALS
Set Backs
—_
Underground Ducts
Forms &Footings
X4Ducts
Slab Grade
_
Return Air
Steel
'Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
d
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
SLOCKWA
0P®OLS
.A PROVALS
-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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
6 (
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
ad
Final
Utility Notice (Perm)
COMMENTS: