9601-101 (PLBG)n LICENSED CONTRACTOR DECLARATION
U) I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
O a
r, License,iSin full4orce and effect. 337333 AB 8/31/96
r,� W License # Lic. Class Exp. Date_#
O.Date ► s< �r� f Signatureof Contractor 1� 1
co H OWNER -BUILDER DECLARATION
J IU 1 hereby affirm that I am exempt from the Contractor's License Law for the
Hd following reason:
Cn ( ) 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
LO
CV
rn WORKER'S COMPENSATION DECLARATION
FL
Q 1 hereby affirm under penalty of perjury one of the following declarations:
C Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
� <O Cc compensation, as provided for by Section 3700 of the Labor Code, for the
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 by
m 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 Z Carrier :•nor;:I Policy No. :1n^ii.a6
qt (This section need not be completed if the permit valuation is for $100.00 or less).
Z)() I certify that in the performance of the work for which this permit is issued,
O 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
t1 G Code, I shall forthwith comply withAh@;se provisions.
Date: Itta t,_ Applicant ,jAtt.R
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 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 IB
correct. I agree to comply with all City, and State laws relating to the buildings
construction, and hereby authorize representatives of this City to enter upon the
•
above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
ALU" BUILDII
DATE VALUATION 51,011(mic LOT
JOB SITE ADDRESS 52-575 EIS�1 MM DR
OWNER
ELEANOR O NE\%r ON
52 575 .EISENHOWER DR
MD10 CA 9220t
USE OF PERNVL1 M6[1tNG
SEPTIC ABA'4f10N/ EW.FJ,2:liOC)K-UP
FEE DESCRIP
VAUTATION
APN 773-295-019
IAC ANIBIL, INC.
51d00t EISEN. GWWER 011-
Lia QUINTA CA, 92253
(619)564-1339 CBL# .2526
DESIGNERIENG[NEER
100.00 iiS
'L?1..UBIQINIG ME — SHWFR 101-000.4194000 $30.00
/41
1,0410.00$
SLIB'CTAL CONa I'RUMON AND PL AIM CIIECK, I 530.00
LV.SS PRE -PAM FEES $0.00
JAN 9 1996
7���
RECEIPT I DA
TOTAL PERMITFEC' S DUE NOW $30.00
l
Pir �
BY
RNALED
INSPECTION RECORD
OPERATION DATE. INSPECTOR
00, BUILDING APPROVALS
Set Backs
Forms &,F ootings
Slab Grade
Steel
Roof Deck
0. K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
i
' 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
Final
BLOCKWALL APPROVALS
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
' 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
• r , ..�;'f:•pa�51T.�;eP.'..+a.:..*^..tom--.7-.r•.S.,,l .�.'�f�S•"f'. 'i•.".T',y �. ..•r+ -T... � � :.i;� `,w4�nTi��iyRi'��t•�� -. -, `".-_.. - :.n�t�.,, i. i,�'�..: �t.R'.^. . . .., v�.af1
COACHELLA VALLEY WATER DISTRICT
��..
CASH RECEIPT DETAIL
Received From:
Address: r•
Account No.( Lot(s)
5
Service Address J -a r� - l.�c. �:1 ., k,>, <
❑ Meter(s)
i 5 Tract-
G.A. Code
G-0,
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check (s)
❑•�
��MeterSurcharge
Charge
�Z?� anitatlon Capacity
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account -Name
❑ Inspection Fee -Tract -
Fee -
❑ Pian Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL J$ �','� 00
1 `
JRemarks: '-°�f r 1 ►1
1 �G' Tt �v
❑Copy to:
Cash Water Service /.
Check
Money =,
%; Cashier
Order _ . �t/WD-438 (11189)
2502 Morongo Trail
Palm Springs,' CA 92264
(619)327-8859
N° 10130
SOLD TO
SHIPPED TO
STREET NO.�y STATE'
STREET NO.
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CITY{j/,� STATE-p�• ZIP
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CITY STATE IP
CUSTOMER ORDER
SALESMAN
TERMS
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PAYMENT DUE UPON RECEIPT