9602-091 (GRES)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
SectiLrh 700"lof Division 3 of the Business and Professionals Code, and my
License is in full force and effect. 360W C -S B 11,IN196
License # Lic. Class h Exp. Date
Date .44 d SignatureofContractor L /�A-�.. y o
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.
( ) 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. are:
Carrier GUNN EAGLE, Policy No.
(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: %( q Applicant [Ila.. - — ��--
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 1 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 purp s:
gignature (Owner/Agent)
AL"BUILDING
PERMIT
PERMIT,t6f)ZA191
DATE 217461-1916
VALUATION "' " LOT TRACT
.i
JOB SITE ADDRESS 5V.()y_j I[NVERNJM�
APN 769-3661.-005
OWNER
CONTRACTOR
'80ETTCH6R CON C1.11~TE C01Y 1.
K €1 &.PA"I'P�. CfAJACKSC7N
54115 E1SEN1i01VVF:fi ,0%
55039.1NV'ERNESS WAS'
f.A QUINTA. CA 92253
LA. QUINTA. CA 92253
(619)564-3411 C131.,>f 2532
(
DESIGNER/ENGINEER
USE OF PERW:07l1-t.t>,tal: ti—� tlxkt "Jtt
001J., CART (2ARAOM
FEE DESCRIPTION
FEES
t3AEiAQJ':t ICAE Pk)1CJ' 40MU 3F
ES,i I NLkY ` D COST OF CON9f RUCTION ION
794.00
PE'IK1l 17 FE'L titJMMARY i
P1. AN CHECK S'EFi 101 -OW -439-31 H $13.65
CONS' 1WC*r10N FM 101-00041&.660 $21.00
C-LECIRICAL FES 101-000.420-000 $15.$0
Pl:!lN NG FrF1 101-000-419-000
ST.IONG MoTt0'rt F13E •-'RESID 1.01.000.241"000 $.50
co
� m
V_
r__4
W
L.L
2
suB-Torr.AL C0NSTfd:1. Cn0Nt AND P1 Ales CF[FCK
$50.95
1.1..SS P.R y,1-)4UD :FE1r8
i
$0.00
TOTAL PERMIT FEES DUF NOW
$50.9.5
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set dicks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath -
Drywall - Int. Lath
Final
Final -
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test .
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
JHh1-�9-$b t1�?t1 1b:Uk3 G'ouch dost Ccr�cvres.Faz F19 ?'121167
AFtCHITECTVRAL,/LANDSCAPE VARIANCE APVLICATION
prep, 4Z T FSID ,NTIAL
Please complete and include this request form, along with
four (4)cets of your proposed home improvement plans to:
FGA WEST RESIDENTUkL ASSOCIATION, INC.
P.O. Box 1060
La Quinta, CA 92253
or, 55-940 PGA Boulevard.
La Quinta, CA 92253
A.ttri, Property Manager
NAME; i'1kwtFy
ADDRESS,
PTION _ UNIT • ._ .._
PROPOSED STARTING DATE:CPS tD
APPRt�X�f�AI;E ,�'ONj�LFTjON 1 1
Humedwnt-t ' a S\jgriature
The following apxopriate intO.Cmation etlould acco«tpany you=
completed application;
1. tour (4) Sete of eompl.ete plana to include:
a. lmprovelnellt- s and/demolit ions
b. Plat plan
c. All dimensions proposed
a. Fclatiori:;3hip to neighboring units
e. Material and color scheme
f, planned modifications of all external systems (landscape,
sprinklers, gars lines, electrical, etc.)
2. AgreemEtzt decd Covenant Running with the Land completed and
not.arized, Two (z; original.
3 ConditiUIW of Approval and Disclaimer torm (signed)
4,* Facing and Adjacent Neighbor form (if applicable)
5. Construction Regulations form (signed)
ELECTRICAL ( ] Approved ( I Disapproved
Signature- _ Date
LANDSCAPE ( ] ,Approved ( ] Disapproved
Signature— Date_
ARCHITECTURAL.0 M Tkkll [ Approved ( ] Disapproved
Signature I� Date
- /�&
ARCH/klev 11/95 l
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