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9511-094 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with CM W Section 7000) of Division 3 of the Business and Professionals Code, and my C:) c-) License is in full force and effect. O U -)y+333 A W3100r W Z License #_ Lic. Class . Date IN- CC Date 1 _ i �— Signatureof Contractor o� Z ccDD 0 a) OWNER -BUILDER DECLARATION WIU I hereby affirm that I am exempt from the Contractor's License Law for the tl following reason: ~ cA () 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 Date Signature of Owner LO N Orn WORKER'S COMPENSATION DECLARATION dQ I hereby affirm under penalty of perjury one of the following declarations: C)g Z () I have and will maintain a certificate of consent to self -insure for workers' Lo HO CE 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. G J J ( ) I have and will maintain workers' compensation insurance, as required by DO Q U Section 3700 of the Labor Code, for the performance of the work for which this O U permit is issued. My workers' compensation insurance carrier & policy no. are: d rn Carrier ��...�-.rn,m Policy No. �.,,�r r ?' Z (This section need not be completed if the permit valuation is for $100.00 or less). r- =) () 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 44 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. iSigna ure (Owner/Agent) Data ALCi BUILDING PERMIT RMITi 1PE9511-b94 DATE 1112WV5 VALUATION S1.0". LOT TRACT JOB SITE ADDRESSAPN 53-745 AV .. HKRRir:RA OWNER I/ 7 CONTRACTOR f Mt IMBI ., INC LA QUINr l'1`. PALMS RL -k1; -1Y Sl 001 EIS"111ONVER DR P.G. BOX 3I6, LA QUINTA CA 9223.1 LAQUINTA CA 922?3 will)st,4-1339 CBL# 2S20 DESIGNERIENGINEER (619)%4-4104 USE OF PERMITWNIU1idlU FEE DESCRIPTION FEES CION i RACT f%NfOUNT t,ti )V.0U LS CSTIMAtTE,D COST Vi" CONSTRUC- r110N 1,000.00 NfuKMI I FF -C, SUMMAKV PLUA4111140 FM -- SF FR 101-000-419-000 $V410 ' t G- SLB -TOTAL CONSMUC'TION AND ALAN CHECK M FPO LESS PRI3-PAID FEES $0 00 TOTAL PERMIT FFF-44 DOF NOW S30.00 • ,� TO T Ai. PRO3FCT PERMIT F FES 30.00 RECEkPT 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 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 Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) I� SA - 4 2502 Morongo Trail PUMPINGG SERVICE g Palm Springs, CA 92264 (619)327 -8859- N2 619)327 -8859- N2 10117 SOLD TO TERMS SHIPPED TO J7 STREET NO.` STA7 STREET NO. CITY STATE ZIP Lam. i CITY STATE IP i .j CUSTOMER ORDER SALESMAN TERMS ATE -VVO.ee. PAYMENT DUE UPON RECEIPT