9510-107 (BLCK)LICENSED CONTRACTOR DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W action 7000) of Division 3 of the Business and Professionals Code, and my
License, is in full force and effect.
O co � i U7 t " 12/31/4;
Q "ansa .# Lk. C _lass f . E'xp. Datlk_ n
Data f t i "
Z � 1 j�i i Signatureoft;,ontractor
d� OWNER -BUILDER DECLARATION
IU .� I hereby affirm that, I an exempt from the Contractor's License Law for the
D_ following reason:
Z ( ) 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).
O I am exempt under Section , B&P:C. for this reason
LO Date Signature of Owner
CV -
O cm
rn
WORKER'S COMPENSATION DECLARATION.
dQ I Hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintain a certificate of Lconsent to -self -insure for workers'
H compensation, as provided for by Section 3700 of the Labor Code; for the
LU u- performance of the work for which this permit is issued.
-J Q ( ) I have and will maintain workers' compensation Insurance, as required by
QU Section 3700 of the Labor Code, for the performance of the work for which' this
U permit is Issued. My workers' compensation insurance carrier & policy no. are:
rn - CarrierSSP T. T�C-411'Policy No. yltions
'T Z (This section need not be completed if the permit valuation l for $100.00 or less).
OD 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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Data: 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
any permit issued as,a result of this application agrees to, & shall, lndem -
& hold harmless the City of Indian Wells, its officers, agents and employe
2. Any permit issued as s result of this application becomes null and vol
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancel Q
I certify that I have read this application and state. that the above info is
correct. I agree to comply with all City, and State laws relating to the, b
construction, and hereby authorize representatives of this City to enter upon fie
above-mentioned property for fins n purpgses.
—Stnature (Owner/Agent):_.?ff &_e Data / !.2
AW"
BUILDING PERMIT
DATE 10/31/95,
VALUATION $224.00 LOT
TRACT
JOB SITE ADDRESS
APN
73-740 WNHAFIi:1[.,�t� D
604 Z3.fl-dDOli
OWNER
OONTRACTOR
AQUA(?UE �T P(XXS
IfUGH R JC ANA BAIL IMT
801 9751&ND10 IBL :'D.
79740 HARLAND DR
PALMDESERT CA 922,55
LA QUIN TA CA 9'22,.1
(619Y345-5070 CALM 130
OESIONERMNOINEER
(,619)345-5070
U.SEOFPER1MTj1 NERAL BUILDING
14' OF 4' HI(Al GARJ:)HN BLOCK WALL IN C()rQJuNi:.7['I0N iNffil ('tial., PF.l(A1'!7''3510-1U2
FEE DESCRIPTION
FEES
a FT, WALL 14.40 L!:
ESTIMATED COST Of," CONSTRUCTION
224.410
PERMITFEF, SUMMARY
CONSTRUCTION FRF l O t tltiU-4l�c-UDU $ i_g.(►tl
SUB -TOTAL CON.S`f1Lt1M I(,�'N AND PLAN CHECK
LESS PRE -PAID FEES
$0.01)
TOTAL PEERMrU F"F"WS WE NOW
T 3
$15.04)
l99�r.
TOTAL PROJEC7 PIr)ltMIT PE1l N
15.00
REC PT
DATE
BY
DATE RUA'En
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
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
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 A P OVALS
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)