9602-112 (PLBG)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. 646826 B ASB 6_1301196
License # Lic. Class Exp. Date
Date'_ ,, SignatureofContractor/�✓ -
Y. y
OWNER -BUILDER DECLARATION
I hereby affirm that 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.
(,4 1 have and will maintain workers' compensation insurance, as required by
Seg%n 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:
Carrier S'TA'fE FUM Policy No. 133147394
(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 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
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 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 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.
IALC # I BUILDING PERMIT IPERM IT%t)Z..'i' ;J I
1140MAS' 14 cC IA11ILYN KI-ELISSElY
54968 1Nvk RNESS IWA ti
LAQ1tJ'j.1`!TACA 92243
(714)760.6793
USE OF
APN
CONTRACTOR ._
VAL�' N'.1W CON fION
41905 flaA111.)WA>: K 90
.P € M .D--tS1F W CA 922.6()
(n19)779-9797 C'B1 P 2_530
DESIGNERIENGINEER
.REPARZ 1NC014REGF OAS1,1.NE 1N.'Tt'A1 LXV10N
E-STIANx:i'.i.Et1) C'(Alf OF CONSTRUCTION
PLUMBY. o FEE 101-000419-000 $10.00
SL3.i3-`1'C)TAL C ONS'' R UC"f10-d AND PLAN C' 1EC'K
. LESS 1': :-PAJD FRES,
TFEB2996
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PERMIT FEES DUENOW
Signature (Owner/Agent) Date I RECEIPT I DATE IBV (DATE FINALED I INSPECTOR
200.410
$10.00
S0.CO
$10.00