9512-135 (RPL)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of. Chapter 9 (commencing with
oj Section 7000) of Division 3 of the Business and Professionals Code, and my
co License is in full force and effect.
0 in 656178 C53 Date 10/31/96
r` w License # Lic. Class Exp.
Z ^ Date_1 - '? _ t, Signatureof Contractor
jT
ai OWNER -BUILDER DECLARATION
J W I hereby affirm that I. am exempt from the Contractor's License Law for the
H0_ following reason:
(A ( ) 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
N
Orn WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
-E Z () I have and will maintain a certificate of consent to self -insure for workers'
Lo compensation, as provided for by Section 3700 of the Labor Code, for the
X w tl performance of the work for which this permit is issued.
O J J ( ) I have and will maintain workers' compensation insurance, as required by
C0 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 LO Carrier r':A(. rci3k p Policy No. W4741i41fl.141 i
�t Z (This section need not be completed if the permit valuation is for $100.00 or less).
r O () 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
0 Code, I shall forthwith comply with those provisions.
Date: I _ > r., , Applicant
Warning: Failure to secure Workers' Compensation coverage istunlawful 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.
Signature (Owner/Agent) 17_-✓fr Date I- Oh
141,
A"'
BUILDING PERMIT
PERMITS
DATE
VALUATION ',i►', z,()(IIjmt
LOT
TRACT -
JOB SITE ADDRESS 79-99S PGA RLQ
PN
OWNER
CONTRACTOR
KSI, Land Corp.
CALWORNMA POOLS & SPAS
41910 BOARDWALK 1#A2
55140 PGA BLVD
PALM DESEWf CA 92260
Lc?!. ('41 rntft CA .92253
(619)340-9000 CBL # 355
777-1274
DESIGNER/ENGINEER
USE OF PERMIVOOL ANJIYOR SPA
Paul culy
FEE DESCRIPTION
FEES
POOL MLl/L IL W ry 12,000.00 LS
. COST OF 6:i)�SaS't RUC" ION
:12,000.00
p, y� y;r � 6 t 6 p,� ,� pEiSSTIMA:TED
PLAN 00,CX F"BE 101.-00(1-439-316 $87,75
CONSTRWt°IC>N FSE 101-000.118-000 $135M
IVGECHANWAL .1'l- -- FOOL 101-000.4.21-000 $24.00
1371J?CrRI AL FEE <-1?OOL 101-000-420-000 S4&00
1'r,C3ivtBTNO Ems -- .POOL 101.-IIW419-000 $27.00
SUB -TOTAL CONS I RUCTION AND 'PLA'N CHECK
' LESS -:PAID FEES
f' $318.15
$0.00
,PRE
®FAL .PC, RART FEES DUE NOW
1996JAN02 ;
PBY_
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
I DATE
I 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
Under round 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Te6ip. Use of Power
R
Final
Utility Notice (Perm)
COMMENTS:
..
I