9510-022 (COMM)„a.. LICENSED CONTRACTOR DECLARATION
1110 reby 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 fullifc�r��pland effect.
License # Lic. Class ,Eyjp. Date
Date .i f SignatureofContractor An n �r�.. , 4
Ill.', 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 hereb�Y affirm under penalty of perjury one of the following declarations:
(7, 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 ;: Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 )3uilding 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, indemnity
& 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. 1 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.
Signature (Owner/Age Date
A`C'
BUILDING PERMIT
PERMITN
a5� ti-4;i� 2
DATE
VALUATION
LOT
TRACT
JOB SITE ADDRESS
7'7-75Cr 5i3Eh eve.
APN
OWNER
CONTRACTOR
1tNPF'I1 IAN C'ON!".MUC” f ON\r
LA. QUINIITA CO't;fld'('1iY C:L
'36660 8ANKSFD13 T-)R..j]
77-750 53ii'iMe.
CNPHEDIRVU, Cft`Y CA 92234
LA QUINTA. G.A. 92253
((61)9)3-24-7
DESIGNER/ENGINEER
USE OF PERMIT COMM
STRUCTURAL ONLY PERi\UT, REMA114L NC3 FEES WULL 13L; C1-1.t11tQE1i U.PON ISSUA:N ICU 0h
FEE
l
DESCRIPTION
v
FEES
08MM.t WD C'ii:3T OF CONSTRUCTION
31.0
PERMIT EC SUMMARY
C'ONSTRUCT10Ntid FE,-IF I0i-WO-418, ){x) M,6$9.50
°I1e.Otr�: 1kiC♦Tt.C1N' r - C�anThs 100-000-241.O t)
D
! CT
Ry
6 1995 . .
sN>B-'a•G°r L CONS'TRUC7110N AND I't.,AN CHJECK.
• x
V,773. 0
LESS TIRE-RAJD F:EES
so,00
TO�yT'AL J<►F# 1V-17 €, T+ F—§ 3?T.i1+ NOW
s�,'�/�( ,.5,)�
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
-INSPECTION RECORD``
OPERATION DATE INSPECTOR
4 BUILDING APPROVALS
Set Backs'
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Fireplace P.L. _
Fireplace T.O.
Party Wail Insulation
Party Wall' Firewall
Exterior Lath
DryHvail , Int. Lath
Final
BLOCKWALL APPROVALS
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping .
Plumbing Top. Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piping
_Gas Test
Appliances-,
Final
Utility Notice (Gas)
` ELECTRICAL APPROVALS
a r
Temp: Power Pole
Underground Conduit
Low Voltage V
Fndures'
.Main Service
-Sub Panels
Exterior Recef
G.F.I. .
Smoke Detect
'Temp. Use of
OPERATION -
;DATE
INSPECTOR
'MECHANICAL APPROVALS
Underground Ducts
-
Ducts
Return Air
Combustion
-Air--
Exhaust Fans;.
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
,
'--.'POOLS - SPAS +
Steel
Electric Bond
j
Main Drain z
,d•
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg., Test -
Gas Piping,
Gas Test
-
Electric Final
Heater Final
;
Plumbing Final
Equipment Enclosure;:_
OX for Finish Plaster
Pool Cover
-�
Encapsulation:
Final
COMMENTS:
2 .
Building Address ss Z 7-750 /
' Add
Owner
Address
City `
r;
ress
City "
State Lic.
8 Classif. '
. ' Arch.; Engr.,
Designer
Zip
4 lvoiocl
P.O. BOX 1504
APPLICATION ;ONLY
78-105 CALLS ESTADo
LA OUINTA, CALIFORNIA'92253
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number 1
TTo,
.
Legal Description
Project Description ,�iin2to
p P Tel.
Lic. N
SIZ SFt: Q p�0
ze jJ 0
New. ❑ Add ❑
D
No. No. Dw.
Stories Units
Alter ❑ Repair:❑ Demolition ❑
Address
City
t l
Zip
State
Lic. N
I
r
'
" * LICENSED CONTRACTOR'S DECLARATION
'
' I hereby affirm that 1 am licensed under crovisione of Chapter 9 (commencing with Section
RIM of Division 3 of the sur►iness and Professions Cods,'and my license is in full forge and
effect.
%QATUwg - - - DATE,
OWNEWBUILDER DECLARATION' ` '
1 hereby affirm. that I. am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.9usness and Professmrn Code: Any City or. County which reoiu a
. permit .to Construct. after, reprove. danoash, or repair any structure, prior to Na Wuae &la ncd
reodns the applicant for such permit to file signed atatamsrtt that he Is licensed pursuant to
Conrraetor's Law. Chapter 9 (Conenarlenp with Section 7000) of
Estimated Valuation'
PERMIT
AMOUNT
the provisions of the Lloense
0hisron 3 of the Business and Professions Code. Or Mat. lie Is ON&T W therefrom. and ftn Data
for the eseged exemption. Any violation of Section 7031.5 by any applicant for a perm►
subjects the applicant to a civil penasy of not more than hive hundred dowrs (f500)•
I, as owner of the Drop", or my employees with wages as their sole compensation, will
do the work, and the structure is not intended or offered for sale. (Sec. 7041, Sulsness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work fiayrseN or throughhis own O byees.
provided that such improvements are nor intended or offend for sale. N. however, the building
of improvement is said within one year of corpierlon, the owner DulMer we have the burden
of proving that he did not Rued or improve for rive purpose of sale.) ... .. _ .. .. .— . _.. _
! : 1, as' owner of the property, am exctusively contracting with licensed contractors to con.
struct the project. (Sec. 7044. Business and Anhssions Code: The Contractor's License law
does not apply to an owner of property who Dullda or improves thereon, and who contracts for
' such prolects wren a contractor(s) licensed pursuant to the Contractor's License Law.)
1 am exempt under Sec. & 8 P.C. for this reason
Plan Chk. Dep.
,
plan, Chk. Berl.
L .
Const
-
Mech.
0'O
Electrical
-
, 7 Q r
Plumbing
87r 570
S.M.I.
Grading
op
Driveway Enc.
Date Owner
Infrastructure
WORKERS', COMPENSATION DECLARATION
"
I hereby affirm that I have a certificate of consent to'self•Insurs, or a certificate of
Worker's Compensation insurance, or a certified copy thereof. (Sec. 3800. Labor Code.)
-.
Policy No. company
f7 Copy is tiled with the city. r Certified copy Is hereby furnished.
--
TOTAL
a d 7, ?3 2 D Z.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be Completed if the pet Nt is for dive hohdrid dollars (11100) vawatlon ;-
REMARKS -7hj4
�"-
-
1 certify treat in the performance of th0 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
Lawn of California
---
ZONE BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line -
Date Owner '
NOTICE -rO APPLICANT: N. after maiip thig Certificate of Exampeon you shade .become
subject to the workers' compensation provisions of the Labor Code, you moat forthwith
compty with such piovisionaa ilea perm shay be d em al revoked.
CONSTRUCTION LENDING AGENCY
Side Street Setback from renter Line
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097. Civil Code.)
Side Setback from Property Line
Lander -a Name
�-- --'- • ----
Lenders Address
,(This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I ague to comply with all city and county ordinances and state laws relating to building
construction, and hereby'authorize representatives -of this city to enter the above.
men9oned property for inspection purposes — - - Y _
FINAL DATE
Issued -by:
Validated by:
INSPECTOR
�__ __•_ ____
Date Permit
_
.Signature of applicant Date
Mailing Address -- — _..
'Validation:
--
City; State,. Zip
- - CONSTR. C':gN EST:.MATE
ELECi91CAL,FEES
;VQ _'-P IUMBING. FEES .-
S. C1
:D Fl
;AR
i .ARP.
. f�YJAI L
I. ST MATED-OC;?+S'. P.L'CTICN
j -
SO. Fr, 4
Sr). FT
SO c-
40 � 1,'..I
SO Fi.
VALUATIC'•J
1.=
UNIiS
I
- /
Imo•
i
PROS K S JS ,A:
I
MOBILEHOME SZ.
BAa C;un`
POWER OUTLET
t
y
, j ayROCF
CPAIIvS
a}
�'
I ORAI"IAGc °.'PING..
-
>,
"
f. DRINKING' FOUNTAIN
I'..
URINAL
S
.. �
I WATER °IoING -
`NOTE Nc: to pe useu as property tax :alLatlon
FLOOR DPJiIN.
f
MECHANICAL FEES
`
WATc4'SOFTENER
'
��1T�S fSTe A FAN �jVAP, ^OvL HOOD
SIGN
WASHEP(AU?O)iDISH
"IPPLIANCE: - DRYER
-
- '_�
GARBAGE OISPOSAL '
FJR"C'E - UNIT WALL FLOOR SUSPENOED
�'
4$:I,
l`AUNORY�TRAY,`
. IR HANDLING UNIT - - CFM
KITCHEN SINK
-
ABSORPTION SYSTEM. B.T.U.
TEMP USE'PERMIT SVC' "
WATER CLOSET
COMPRESSOR - H.P
POLE, TEMIPERM'
LAVXTORY
,HEATING; SYSTEM,. FORCED GRAVITY .
AMPERESSERVENT
..
SHOWER
BOILER ..' B.T.U.
SG: FT c c' . D Z
..:" f
:
BATH UB';
SO. FTz 4 r
WATER HEATER
MAX. HEATER OUTPUT. B.T.U.
SO.'FT. RESID.W.t w c
_.
SEWAGE' DISVOSAI
--- -
_.. SO.FT.GAR atr..c_
HOUSE SEWER '
1`.
GAS PIPING. -
-
PERMIT FEE
PERMIT FEEl.,
r
PERMIT FEE.
OBL
TOTAL FEES
MICRO FEE
MECH.FEE
PL GK.FEE
CONST `FEE
ELECT FEE '
SMI FEE
PLUMS. FEE
STRUCTURE
— ..-._ PLUMBING
ELECTRICALMEATINGB
AIR COND
SOIAR , -
9ETBACK
GROUND PUIMBING
UNDERGROUND -
;A.0 UNIT
COLL AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING, (ROUGH)-
STORAGE TANK
FORMS <
SEWER OR SEPTIC TANK
ROUOM WIRING
DUCT WORK -
i. ROCK STORAGE
y 4 , FOUND";REINF.
GAS (ROUGH)
METER LOOP
: HEATING (01NAQ' S
OTHER APPJEOUIP.
rREINF. STEEL` ":
GAS (FINAL)
TEMP. POLE .
GROUT - —
-'
WATER HEATER
SERVICE
FINAL INSP.
e
+ BONO BEAM
WATER SYSTEM
;GRADING.- ,
r .LUMBER GR..
--
FINAL9NSP—_....
.d
U%y:�—
_
-FRAMING _
FINAL INSP.`plus
y -A `
_!
ROOFING:'
REMARKS.
' :y :VENTILATION.
-
-
FIRE ZONE ROOFING
FIREPLACE
Cry'
SPARK'ARRESTOR
GAR FIREWALL
g/ 9�+ ' .w
GG
4..
LATHING
i O
MESH _
- --
INSULATIOWSOUNO
FINISH GRADING
f, INAL INSPECTION
...
.
;,-FENCE FINAL
INSPECTOR'S SIGNATURES(INITIALS y.: s '.`-
i,
�. ;GARDEN WALL -FINAL
Y i.
Building
ner
Address
City .
Zip
4.14
P.O. BOX 1504 APPLICATION ONLY
78-105 CALLE ESTADO
LA OUINTA, CALIFORNIA 92253
BUILDING: TYPE CONST. OCC. GRP,
Contractor I
Address
City . Iz1p I ref. .
State Lic. I vttY
& Classif. LiC. N
Designer
Address . Tel.
City Zip State
Lic. N
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
T000) of Division 3 of the Susiness'and Professions Code, and my license is in full force and
effect.
ar.NATLRE DATE
OWNER•eUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5.9utWeas and Profession .Coda: Any dry or county wMeh requires a
ponce! to Construct. seer. improve. damodsh. or repair any 3bueDsa, 06W to its baurncs abo
rewwes the applicant for such Pamte to file a "Red staterlMf that he is licensed pY/sWnf to
the provisions of the Contractor's License Law, Chapter 9 (coo - t.nesp with Section 70001 of
Olvision 3 of the Business and Professions Code. Of Mat. he is exempt th*Wmm, and NN Dub
for this 'aaeged exemption. Any viWation of SeCNon 7031.5 by any eppseant for a perms
subjects the applicant to a civil penalty of not more Man Nve hundred dollars (S500).
11 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 sass. (Sec. 7044, Bubnau.atW
P%Isssons Code: The Contractor's License Law does nor apply to an owner of property who
brdds or improves thsroon arc who doss strWn work hdynaen or Mralpn htb own erpbyaes.
provided (flat such inprovems"M are not imends0 or offend for to sofa. N. however.. the iditg
or improvement is sold well"ear of completion• the owne one yew wfs have the burden
of proving that he did not bus of Improve for the Purpose W sale.)
I, as owner of the properly, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044. Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who bu*la or Improvise fhanon• and who contract .for
such projects with a contractor(s) licensed pursuant to the Contractor's. License Law.)
1 am exempt under See. a. a P.C. for thlit reason
'Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sslf•Insure, or a certificate of
Worker's Compensation Insurance,.or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company .
i7 Copy is filed with the city. C Certified copy Is hereby furnished.
CERTIFICATE OF EI(EMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be conpbfed a Me perm Is for one hLoQ W dollars (t 100) valuation
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. ....
Date Owner
NOT)CE TO APPLICANT: N. after maiitg this CerNieare W Exemption you should became
subject to the "rkers' Conpensation provisions of the Labor Code, you must forthwith
comply with such provisions or this Permit shelf be deemed revoked.
CONSTRUCTION LENDING•AGENCY
1 hereby affirm that there. is a construction lending agency for the performance of the
work for which this permit is issued. (Sec.. 3097. Chit Cade.) '
Lender's Name
Lender's Address
„Thls is a building permit when property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
.I certify that 1 have read this application and state that the above information is correct.
' I agtwe to comply with all city and county ordinances and state laws relating to building
cohstnt ction, and hereby authorize representatives -of this City to enter the above•
menLioned properly for inspection purposes.
P. Number
Description
Description
Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
toOQOQO QO
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Sal.
Const.
0
r1
Mech.
Electrical
Plumbing
S.M.I.
. ._ ..
r�
Grading
Driveway Enc.
Infrastructure
TOTAL
7✓7
REMARKS
ZONE BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line --
Side Street Setback from Center Line
Side. Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by:
Signature of applicant Date
Mailing Address ----.._. _ — _.: .-Validation:
City; State, Zip 1
-
C - CONSTP.uCC;6NES?iMA�t YO. EIELTAICAI°£ES
N0: �°1UM81NG r,EES
D l f SO. F7. t i j t sAp g, < S'•S"
I _ _ MOSILEHOME Ln -. .. 3A P.°.yK3 X ..
SO F? POWER rUTIET w s POCr 0PAINS
1
=r' i' r ` I nQAI�10Gc oi°ING •� 5.
� aRnP .5� SO
_, Y141L SO. FT. - .. :I' : 2 -'�- �ORINKING FOJMFAIN
URINAL• ''`� F,'•'
SO FT �'• f i
YS`.., ,UA n„C.,y S'. P,UCTIrN VALUATIO^! 4 .. I.,. r• IWATER;ototNG
17, uCTE. rvc to �e',seu as Property tax valuation.,
t FLOOR'OPAIN ,
MECHANICAL FEES.( vtrWATE?SOF SNER
rAN _VAP COOL HOOD SIGNWASHER(AU 0)IDISHI - �Y..,'•
`PRLAANCE - - ,DRYER ` GARBAGE DI°POSAL -
FURNACE-`'CYIr WALL FLOOR SUSPENDED'-
AIR- HANDLING UNIT - .CFM ,F, r ` ,:.. r. KITCHEN SINK - -
PBSORPTION,SYSTEM B.T.U. TEMP 'USE -PERM)T:SVC s`• f3 ` ;�•' WATERCLOSET�.'
COAAPRESSOR'_ H.P - pOLE','TEMIPEHM
LAVATORY
:.
HEATING SYSTEM_• FORCED GRAVITY AMP.ERES'SERV ENT • J SNOv�ER i
BOILER B.T.U. _ SO. FT 6' C, +, BATN;:TUB
' y SO. FT4 c '' ;+ WATER HEATER
AAX'HEJT '&TPUT. S. T. U. .SO FT'RESIOGp t'a'c .,;,_ q .'h SEWAGE DISPOSAL
SO.FT.GAR rd;c HOUSE- SEWER . t
GAS
PERMIT FEE PER
MIT,FEE i it f , zrµ PERMIT FEE ; =_
DBL TOTAL FEES MICRO FEE MECH.FEE PLCK.FEE CONST: FEE, ELECT FEE SMI FEE'.': PLUMB>FEE
- STRUCTURE - :..._ PLUMBING ELECTRICAL, HEATING WAIR ONO 30LAR
T SETBACK. - GROUND PLUMBING UNDERGROUND.. A C UNIT ,
' ' f6COLl. AREA
_ -. .. f
SLAB GRADE ROUGH PLUMB. BONDING „:HEATING¢(ROUGH) i " r. k STORAGE TANK
FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WOfiK vZ ROCK STORAGE, s s
a,T
FOUND REINF.' GAS (ROUGH) METER LOOP HEATING (FINAU s x OTHER APPlEGU1P
* i
�REINF STEEL GAS (FINAL) TEMP. POLE
a
GROUT - - ' - WATER HEATER SERVICE `� FINAL INSPz ' `''' '? *;
4i
t c+ BOND BEAM, WATER SYSTEM
x ;...,GRADING - - --•— - ��,. :.
z ynLUMBER GR '. -- FINAL INSP. } �� ye
s FRAMING( FINAL INSP. f plus
t.
y
,3 ROOFING!", REMARKS
R
,VENTILATION
-• -----•----- --- - -- ass.
{ FIRE ZONE; ROOFING
FIREPLACE. r t s
SPARK ARRESTOR
_. -- --
:v
t y LATHING
MESH r
S INSUI.AT10WSOUNO
� FINISH GRADING'
FINAL INSPECTION
CERT OCC::
a
FENCE FINAL' -
INSPECTOR'S SIGNATURESIINITIALS z x
r" a GARDEN WAIL -FINAL i_, '+.-✓. a r.
4,
RIVERSIDE COUNTY << ��uFOANi�.
FIRE D$PARTMEN'I' ;
PENVTnOT C��'�qy
c>)uNrr '''
IN COOPERATION WITH -THE
QEP�PF
R/Y6RS16 , ,
4 CA NAIA{0EPAgtw.tiJT,0F FORESTRY,
UFOR
�
_...
f l�r dROTECTION
C
� t
TOi ®UILDING & -SAFETY.,,DEPARTMENT.
DATE
The Riverside County Fire. Department considers `its r.equi,rements ,y
met,��nd hearby reaeasea
the.foa.lowinq project and/or` buil:ding(s)
for' occupancy.a
�5a
ADDRESS e--_r �s.2cy!
J
Uri/
RAYMOND H . .REG I S
Chiit, Fire Department' --Planner
13
ccsf.f.le
� �•
1. - .
�
r , •
i
y'
1
•. - .. '
r