9511-032 (MISC)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. 14461
,License # Lic. Class Exp. Date
'Date Signatureof Contractor
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).
(;v)'r 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.
( JAI 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 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 agr�e@ that if I should become
subject to the workers' compensation provisions,617'ection 3700 of the Labor
Code, I shall, forthwith comply with,those provisions'
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.
IALcar I RIM nlKI�`_ OCQIIAIT [PERMIT �z
I JVtl Jilt AUUMbb A ('11T' 1N'1CA RESORT
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ID
11.0. BOX 3166
PALM MSElt:i' CA 02 6t
A - ! RFNTAi.S
57m wrn "i SPRINGS RD
PALM SPRINGS to 4226.1
ftalq)327-1111 t.11LA
DESIGNERIENGINEER
'I'1;'h•11'tlkAi�Y 7'fiN'I' t•'t);;2 'I'l3�'t.3'j'A fvlt�'}'t 1k C't Nt1'()ttA'1'K)N. S'PRt}t. I'ifkl~'I'�) itklNAl fv � ►[ '+t'}•i:
FROM Nt ►VFiM3ER 7, 199%'F0 W IYM- 111FA 9. 1"5. SP'ht 9AL IN.VE( TION
FEE DESC
t;t)i'tiTHA47t' AMc/tlNT S,tiINI I>•) t.5
ESTIMATED COST OF CON:STliii(TION
PERMIT l+EK SUMMARY
ty91`#i'i,l.i 4NrOUS illl•ft{N}-d?-ftal(1 Slim) 100
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, repress �tives of this City to enter upon the
above -mentioned proper, or in pectionypurpos�s.
,401 , I
Signature (Owner/Agent) v tr'�' Date /t ke" �r RECEIPT
;ti!i�•'l't's1'�1L C;UNS','lt(`f:"fit.)*, ai�:i.► P3,.1�3 :.'iil:'F;.
LPS? ; PR -PAID iTil"S
DATE
Y01A1, Vk0.IM',t`f PER1VIti'>I; ViS
INSPECTOR
6.{".04i
$100 Ot:
$0 W
S l ll0,"
100.4"1
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR.
1L"
BUILDING APPROVALS I MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
PLUMBING APPROVALS
I Shower Pans
I Gas Test
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underaround Plba. Test
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
OX for Finish Plaster
Pool Cover
POOLS - SPAS
Final
COMMENTS:.
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm)