9511-086 (PAT)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
License is in full force and effect. 4'1b807 C.;) 12!3!/95
License #_ Lic. Class Exp. Date
Data Signatureof Contractor
ixt OWNER -BUILDER DECLARATION
I hereby affirm A I am exempt from the Contractor's License Law for the
following reason:
( ) 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).
( ) 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 self -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. we:
Carrier g ;,ATr., j:7 rnn i Policy No:. 6773M.
(This section need not be completed if the permit valuation is for $100.00 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 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
Woming: Failure to secure Workers' Compensation coverage is unlawful end.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, Interestand.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 madeA 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.A,��/�
2. Any permit issued as a result of this application becomes null and void if,1
work is not commenced within ISO days from date of issuance. of su
permit; or cessation of work for 180 days will subject permit to cancellat
I certify that I have read this application and state that the above inform is
correct. I agree to comply with all City, and State laws relating to the bull
construction, and hereby authorize representatives of this City to enter upon the.
above-mentioned property for inspection purposes.
(Owner/Agent) Date %j 1r.•l�" �I.1
""'
BUILDING PERMIT
PERtr1ITy51.-11134
DATE ' 11/17tq!!
t: 41
VALUATION S2,9zid,d)dl LOT TRACT
JOWSITE ADORESP
APN
OWNER
CONTRACTOR.
-..
AQ1, JA.QUES']`'1'f Illi,,,'
t3A NIVIT
'00-9,75 f r1T.11i ! t3.I.N.T.
783-740 W. C-Tt' RLAiNli
PALM DESEWr CA 92255
LA QUf NTA CA 92253
yst!�I m5-5070 0.131.4 130
DESIGNERIENGINEER
USE OF PERNPA-117
FEE DESCRIPTION
FEES
i ORCi-PA.i'1O -iQ.0) 5I
9ST11.A 3 ED Gia OF CONSTRUM ION
2,128.00
Pik 01111 ' SEE, SUMNIARV
FLAN (: TFR-, : FT -T, 101-flo(!-day-3it+ $35.10
i:URi;iTtit !'iGN1;Ef lot --000.418-000 $51.00
STONO INIOTION FSE - t'1i;SID 100-000-21.1-600 &so
SUB-TCYYAl. t'OtdS RUC -R N AND PLAN CHECK
589.60
LESS PREPAID i FES
$0.00
ro'irAJ, PERMIT IT ➢+'lh IUS VVE NOW
:589.641
1995 'fO'i'AL FRt3.iE I PERMi l 3"°ETS
89,60
RECBPTDATE
BY
DATE FiNALED
INSPECTOR
INSPECTION- RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturn
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O:K.to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents.
Fireplace P.L.
Grill's
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath -
Drywall - Int: Lath
Final
Final
BLOCKWAL'e A PROVALS
POOLS - SPAS
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
OX 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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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