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0511-025 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing w r W 1; ectioh 7,000) of Division 3 of the Business and Professionals Code, and I C:) ^ C3 Lo License is in full force and effect. 1439y7 H Y31/ 96 r W License # Lic. Class Z Exp. Date nCC r 4Date Signatureof Contractor )SAA 1�-r 6 Z t, F_ o) OWNER -BUILDER DECLARATION J W 1 hereby affirm that I am exempt from the Contractor's License Law for 1 following reason: En( ) I, as owner of the property, or my employees with wages as their si Z compensation, will do the work, and the structure Is not intended or offered sale (Sec. 7044, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licens contractors to construct the project (Sec. 7044, Business & Professionals Cod ( ) I am exempt under Section B&P.C. for this reason CO Date Signature of Owner LON O rn WORKER'S COMPENSATION DECLARATION a. Q I hereby affirm under penalty of perjury one of the following declarations: C) 2 Z ( ) I have and will maintain a certificate of consent to self -insure for worke u-) H O compensation, as provided for by Section 3700 of the Labor Code, for i X W LL performance of the work for which this permit is issued. p J J ( ) I have and will maintain workers' compensation insurance, as required m Q U Section 3700 of the Labor Code, for the performance of the work for which ti O U permit is issued. My workers' compensation insurance carrier & policy no. a d Carrier STATE M4D Policy No. 2299923%l Z (This section need not be completed if the permit valuation is for $100.00 or les n =)() I certify that in the performance of the work for which this permit is issue d I shall not employ any person in any manner so as to become subject to t workers' compensation laws of California, and agree that if I should becor subject to the workers' compensation provisions of Section 3700 of the Lal Code, I shall forthwith comply with those provisions. Date: Applicant 3 Warning: Failure to secure Workers' Compensation coverage is unlawful and sh subject an employer to criminal penalties and civil fines up to $100,000, addition to the cost of compensation, damages as provided for in Section 37 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safi for a permit subject to the conditions and restrictions set forth on his applicatic 1. Each person upon whose behalf this application is made & each person a whose request and for whose benefit work is performed under or pursuant tc any permit issued as a result of this application agrees to, & shall, indemnifi & 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 i 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 correct. I agree to comply with all City, and State laws relating to the buildi. construction, and hereby authorize representatives of this City to enter upon t • above-mentioned properrtty for inspection purposes. ignature (Owner/Agent) �ii,Date j/ AL" BUILDING PERMIT PERMIT,8,s ith DATE sr VALUATION LOT TRACT ny JOB SITE ADDRESS U -SM EISEti11©WER APN — OWNER CONTRACTOR — WILLIAM ] COX & SONS WILLIAM J. COX & SONS btiVO DILLON RD he 6090 DILLON RD. PALM DESERT CA 922o PALM DESERT CA 92261 6192S13780 (2131.# 12o, )le for 6192513780 DESIGNER/ENGINEER ad USE OF PERMITAi ii f:A,4l i I LL)94r .i e). 210 L.F. OF CUM6INrlilUN 13LOCK WALT, FEE DESCRIPTION FEES 6 Fr. WALL 21U.00 LF rs' he by lis re: _ ESMIMATEA COST OF CONS' R UCTiON -S, 2 M 00 s)• t'rr,KAUT i' ICK SUMMARY id, he ne for all \ in 0 06 1/0 4� 9S Ity In. t SUB=T YLAL CONST'RUC710N AND PLAN CHECK $8100 LESS PRE-13AID FEES $Q O TOTAL PERMIT F IsMS DTIF NOW $811.00 is rOTAT, PRO. E(J PERN11T FEVS $1.60 ,Ig he RECEIPT DATE BY DATE FINALED INSPECTOR -INSPECTION REC ORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR ;y BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof peck 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 BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover 2/ Equipment Location ZZ S Underground Electric /9 Underground Plbg. Test Final Gas Piping LUMBINd_0 OV 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 s Test Appliances Final Final Utility Notice (Gas) . ELECTRICAL 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) APPROVALS COMMENTS: I�J.DldSSVI �INIIOILLVIIVISNI Ol 103 1333V MIMOZIMIGN03 13AIRM30. k13:3'VS IS` VINino vi, jo ki,01