9601-030 (RPL)to LICENSED CONTRACTOR DECLARATION
H I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
r W Section 7000) of Division 3 of the Business and Professionals Code, and my
co
o O � License is in full force and effect. 574,,127 %1 A 831M
W cense # Lic. Class I 1 Exp,,Date!O ,
ZDate / L Signatureof Contractor x :1 � AAA4,_ t��
FOWNER -BUILDER DECLARATION
J W 1 hereby affirm that I am exempt from the Contractor's License Law for the
CL following reason:
U) ( ) 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
co Date Signature of Owner
LON
Orn
U WORKER'S COMPENSATION DECLARATION
FL Q 1 hereby affirm under penalty of perjury one of the following declarations:
Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo H WO 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
d U permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn Carrier Policy No.
Z (This sect ptngedj%q1.&p completed if the permit valuatiop i.,sJgr,,$J.90.00 or less).
cb 5 () 1 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' compensationhprovisions of Section 3,.M of the Labor
Code, I shall forthwith comply with do : provisions.
Date: 2 leg Applicant 1.1 �.� .
Warni g. 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 ori 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 purpose
�Signature (Owner/Agent) a rl'� +""' aft. Date
ALCM
9
BUILDING PERMIT PERMIT.t_1!!►►-+}
DATE t t1190
VALUATION r.i.24� ) .1YYiI LOT
TRACT
1
JOB SITE ADDRESS 55-1241 IN 1•'X1.0 f ISS
APN
OWNER
CONTRACTOR
Tl']' -,VF, D USON COMISTRUr" 110N
{
A I1 fi��
4.. .1.rF r„7
� J.A l�.il\ �J asv. �Fr
-
4,t ME
C.f1'V118i)RAL WY CA 92234
t,A, QU1N'TA CA 92153
(619)324-1232 CBL# .10411
DESIGNERIENGINEER
USE OF PERM V(JOL A N V1 X ,,' .A
POOL ANI) SPA ONLY 3'5" REAR YARD ANT) Z StOti VA.RD.REVUC"[ t0N,Ft6JPX0Vh' 3 PM- SHA
�tt,3fia, �
FEE DESCRIPTION p
FEES
CON'r..RAC 1' AMOUNT 18#900 LS
TMIATFI) MST or. coNsTRiiCTION
1810 0.00
i1AERMIT Uri, SUMMARY
PLM 011301 FF16 10-r?0(?»43 <31.8 $122.85
CONSTkuC'I'IONFEb, 101 i(lD.418-000 $189.00
AffiCr)ANIGAIs M, -- POOL 101.-000,421-000 $24,00
is�,CCTk1IC/U,. FEF, K)oi 101-000-421.OW 34.3.00
Pt F; N1WG40 .r'FX POOL 1014900-419.000 $27.00
r•S
SM .. N TIONAND PLAN C14ECK
$407:85
LESS PRF.-.PRA17D FEES
D•
$0.00
JAN1:2.199 ,RMrr 1i•Ers DUD N0W
Sa417. �
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR