9511-036 (PLBG)- LICENSED CONTRACTOR DECLARATION 1
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
� License is in full force and effect. �f39994 ' 3t) 33.1/36
r Lu - License # LIC. Class '%- -Exp Date .
P_ . �aaSe 7 t/ I Signature of Contractore't lJ
� Z � - --moi �
cTo p a) / OWNER -BUILDER DECLARATION
JQ - I hereby affirm that I am exempt from the Contractor's License Law for the
LU W following reason:
I.- CL
( ) 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
M Date Signature of Owner
N
UO rn WORKER'S COMPENSATION DECLARATION
CL Q 1 hereby affirm under penalty of perjury one of the following declarations:
v2 Z () I have and will maintain a certificate of consent to self -insure for workers'
LO < O Ir compensation, as provided for by Section 3700 of the Labor Code, for the
I -ZX 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
ca Q U Section 3700 of the Labor Code, for the performance of the work for which this
' O U permit is is§ ec , ,fly Worke s',pompensation insurance carrier & policy no. are:
CL rn Carrier i. .c3 [ iJ.rJ t3gdrFRU Policy No.
It. Z (This section need not be completed if the permit valuation is for $100.00 or less).
�
C3 () 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, 1 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 J
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
correct. I agree to comply with all City, and State laws/relating to the building
`. construction, and hereby authorize,representatives ois City to enter upon the
• above-mentioned property_for`i _spection purposes..G
Signature (Croner/Agent) �r� Dam'
A`°'
BUILDING PERMIT
f}
-
DATE ` '
DATE
VALUATION '" " LOT
TRACT
JOB SITE ADDRESS 5"2,J ,4.V „ .HERRE to
APN 774._UMIS
OWNER
CONTRACTOR
W01T COMPANY
Ji)L.iA E SAYS
P.O. BOX 2196
5462 i. AVI NIDA HER.I%ERA
I,NDIO CA 922iO
LA QUKi'A CA 92253
(61a):�12.-z05 CBI,#
(0 )
DESIGNER/ENGINEER
USE OF PERMIT a.wivl+ai.tvw
FEE DESCRIPTION
FEES
I.ViYAlth1�:1 NLV'IVtJ VA 1,�W, U LS
STB.tvUT ED COST 01" CONSTRUC' 10N,
IX1.r10
PERMIT FUC SUMMARY
PT.d31OM FEE -- SEWER 101-000-419-000
o SUB -TOTAL, CONMUCTION AND PLAN CRECK,
$30.00
LR SS PRE -PAID FEES
${1.00
�J®V 0 7 19
S 'ifD"I.;tdL VROaiECT PERNuT nvs
30,00
ECEIPT
DATE
BY
DATE RNALED
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
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
Pool Cover
Sewer Connection
"Encapsulation
Gas Piping
Gas Test
Appliances
Ait D
Final
Final / y
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.L
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
,t
4
E'ir•.':�^:'..--^.:--=
etr^._Y..K.p-�•����T•• :T,•�
775.�I-V
.•.s'
Received F
Address:
Account N
Service Ad
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
O House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Pian Check Fees Water I Sewer -
Tract -
❑ Bond Payment A.D. - Bond
Assmt.
❑ CustomerDeposlt
❑ Other
COACHELLA VALLEY WATER DISTRICTtq °9 f
CASH RECEIPT DETAIL f
Remarks:
a
❑ Copy to:
Cash Water Service
Check "+ rq
Money CashierCy
r
Mailing Address: Box 1266 - PALM DESERT, CA 82261
Phone: 328-6718 / 3464916
N? 66036
Calif. $tete Cofnractofa/ Ucease No. 310813 1 / — —7— 5 �6-
Name OTenant
Job at
City �.Q Pa,2,, A� Zip
DATE
WORKMAN
Bili to _ ustomer 0 NewCustomer
At Classification
City Zip Telephone ( )
WORK AUTHORIZATION - I / We hereby authorize the work described along With
the necessary materials and parts
WORKORDE
` ,
Time
From
To
Hours MATERIAL USED
AMOUNT
Mon.
Tues.
Wed.
Thurs.
Fd.
- o
Sal
Sun.
Total Hours
ENTERED
IrlVoke
Journal
Ledger
Cards s ,
WAIVER OF RIGHT TO CANCEL
Having Initiated a contract in connection with emergency
repairs or service for the Immediate protection of persons or
real and personaf property, I hereby state at the If ng
emergency situation exists, requiring Immediate atOenttlion:
Pursuant to Section 1689.13 of the California Civil Code, I
acknowledge and hereby waive all rights to cancel the sale
within three days.
Dated Buyees Signature
TO OUR CUSTOMERS: Service men are required to have work slip signed. This Is done In order to protect you, the workmen, and ourselves, and
to enable us to give you absolute satisfactory service. You are respectfully requested to examine material and labor statement before workmen
goffice
leave the job, and if you find everything Satisfactory, okay this ticket. and�Iff serviceIsunsatisfactory, in any way, please phone our
Immediately.ree to
Amo nable des for collection nGud� a�ttom�efees in hie event of my default A PENALN WILL BE CHARGsentatron E and AuMer AT THE RATE OF
itrz% PER MONTH ON UNPAID BALANCES AFTER 30 DAYS OF INVOICE DATE. ANNUAL PERCENTAGE RATE 1996.
Contractors are required by law to be licensed and regulated by
the Contractors'State License Board. Anyquestionsconcerninga signed
contractor may be referred to the registrar of the board whose
address is: Contractors' State License Board, 9835 Goethe Road, BY.
Sacramento, CA 95827, P.O. Box 26000, Sacramento, CA 95826. I
Total Material
Tax
Service
Permits- Insurance
Trucks-Equipirieril:
TOTAL
01995 by John B. Reeves & Son
LteeUCS BUSINESS FORMS . SM Warner Drive, Cuher City. CA==
Form 31 WAC