9510-077 (ELEC)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
cense is in full force and effect. �3,t1 2/29/96
'cense #_ Lice.asa ; .Jp^Dail
Mats /a .1 ' SignatureofContractor ! ; . ". [ '/�• �'u .
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's LicenseLaw for the
following reason:
( ) I, as owner of the property, or my employees with wages os 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)..
O 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 sell -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: are:
CarrierPolicy No.
(This sectjon''nee ^not be completed if the permit valuation is fOr $ :00 or less):
() I certify that in the performance of the work for which this permit is issued,
I shell not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if 1 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•resuk 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 abovwInformation 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:
i r
Signature (Owner/Agsrd) f .l� ,1: i ra . Dame A) =
"`C'
BUILDING PERMIT
PERMITg�9E=4177
GATE ilttl $Ja�pi
VALUATION$4f141AW LOT TRACT
JOB SITE ADDRESS
44-970 W. d�t�:8..:#.;� O DR.
APN
OWNER
CONTRACTOR a
ACACIA comsrRLICi'im
AO;ACtr1.Ct5PlS1111f. CT1.ON
I;! 41 f -,Ag' KAISER II1. VD., f`
44-87u 1N. H.t'.Ri,AND DR. -
AN.AH.8iivl CA 92908
ANAHJ34M CA 921308
014i 2X2 _Sl00 e: BLPI, 1612
DESxiNERIENGINEER
171.1 2-_-R)0
USE OF PEAWT; Li c; f'PJC A
MOVER FIFI -, S` iM, FOR. RVI'1.-'NTK<jN BASIN 1.ANt:).`rCAPIN:}
FEE DESCRIPTION
FEES
C'ON FRAC 1' A?vl LJN't' 166.66 L i
ESTIJY1{Xi D CCS A ()V'l.'0NS tt *%TJt;�l ON
1J ,lt,WT FVE SUNNI i'it 14Y
Esl.IvC1 RICA1. F')T 1011-01()()4' 0-000
.
)OCT241995
Sr f13-'MT.A1.. Ct)MSTRlJt TION AND PLAN CIii:C:l".
$33.40
LESS PR.I -PAID FEES
$O.UO
"I'C;TA. P ER(1 iT VVEN
$33.50
T%iTAI, PiY4: JE(I i alb lWi.T FEES
3IS0
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
(BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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 Wali 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•Pibg. 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)