9510-058 (COMM)CU) LICENSED CONTRACTOWDECLARATION .
17here6y affirm that I'am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of. Division 3 of the,. Business and Professionals Code, and -my
oI� d In License'is In'full force and effect. 416304 12i�1,1�13
�� W • _ License, # • ,_ Uc Class� a,'' ExP ate-'- -
Si natureof Contractor'I
g
- Z
r �.P: o) OWNER -BUILDER DECLARATION
U; I -hereby - affirm, that I: am exempt from the Contractor's' License Law for'the
' F--'IL • following reason:
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).
O 1, .as owner of the, -property- am exclusively -;contracting-withr licensed
contractors to construct the -project (Sec. 7044, Business &' Professionals Code).
1 O 'I am exempt under Section B&P.C.f'r this reason
Date" SignatureofOwner
LO
...
Ni WORKEWS COMPENSATION DECLARATION'
U .-
�: a.Q I hereby affirm under penalty of perjury one of the following declarations:
p 2 Z O I have and will maintain'a certificate of consent to self.insure for workers'
Ln\< 0_,_, compensation,,as provided for, by -Section 3700 of the Labor' Code, for the
X W=LL performance of;thp,work for which this permit is'issued.
p J J (`.) I'have and will. maintain workers' compensation insurance, as required by
�m ;QU Section 3700 of the Labor Code, for the performance of the work for which this
pu, Q .• .permit is issued.. My workers' compensation insurance carrier & policy no. are:
� _Carrier d,0V FJTIzAnLE Policy No. 1pi('?9t,4i51ff4'
Z ^ (This section need not becompleted if the permit valuation is for $100.00 or less).
co
O: I certify that in the performance of the work for which this permit is issued,
shall not em Io an person, in an manner so as to become sub ect,to, the
P y•..•Y P Y 1
_1 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' Compensationcoverage is.unlawful and shall
subject an employer to' criminal penalties and, civil fines up to $100;0001 in
® addition to the cost of compensation; damages as provided for ,in Se6tion'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.
d F' ►. 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,
(':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
i . construction, and hereby/lu oriie epresentatives of this City to enter upon the
• •above -mentioned ro e • for ins ectlori ur oses
P P i, P P
(
Si nature OwreriA9ant _T Date
18 . )
ALCM
RUILDING:PERMIT
PERM IT
DATE 1W1.7/.1'9"
VALUATION_ ; ;4b4t
COT TRACT
.. . .
"JOB SITE ADDRESS ..
77750 AVENUE S!3
APN
i+ =��iB i?ib
OWNER
:CONTRACTOR -
•-
'I A QUaNTA COUNIr'I'R f ICILU
P:C2. nOX 1.S
17750AVENUE 50 . ..
YCJiiT3� �,iND1� CA! _92686
i :f.?tJ[NT 1 CA. 92253
(61913221.7929 r Ci 1"I'l
(61 )564.4151
DESIGNERitNGINEER
USE OF PERW,T 0111ivII'JtC1AI,
ij "I'ENANf- Mff1RQVF.,% NT - SallvLac i'AF v `Smut ,-64AL PEKAMT 9310�02.2.
FEE DESCRIPTION
FEES
,e'LRAHT FEE SUMMARY
. bF�l'JF.J?�7tif�C ,4, °' >: �l,oa�:rxt
- •
P1AN'CtmC°1k.vit. tot-t)O()-439F318
ptv titU rte7nYt�E;et 101-060-418-000
MECH'ANTCAL FEE 141-Qtt(i-a1.t= t►r) isH.uc, ...
1*.0 'l:'Itf.CAL..FE 101_000-420-OW $2,70,50
PI,UAWNG FER " ;101-000419.-000 -' 187s50
tz.
STONG IM01'.10 14I'ni :RESU) tfKi-fIM2' 4al 0i}(3 .
,.
O AMNG .FEE, ... 101-000-423_{i00
CT 17 1995-_:
R
Y
B-T ,,~�,AT fir;�rS RIT�TIG1I`+ �1RtTti1 PIWnar V.'l : r
% LESS 'PRE-12A1:t.? FEES
41,00.00
TOTAL PERM' FEES DIVE; NOXV
SIP107,42
RECEIPT
DATE "
BV
DATE FINALEO' - - -'
INSPECTOR -
`e
-, INSPECTION RECORD` t� r
^
�' »,OPERATION
DATE
INSPECTOR
OPERATION
;DATE ,
.,'INSPECTOR
BUILDING APPROVALS..'MECHANICAL
APPROVALS.
Set Backs.
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.
Tans & Controls:
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Later
Drywall , Int. Lath
"5
j
Final
FinaV
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 > '
Gas Piping, -
` PLUMBING APPROVALS
Gas Test
Electric Final
r
Waste tines
Heater Final
Water Piping
Plumbing Final
'
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster •
-
, .�.. , '
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test;
Appliances .
Final
COMMENTS
;
_
`µ
,
,
; :, • y «"
.�
Final
Utility Notice; (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring:
Low Voltage.Wiiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp..Use of Power
.
Final
Utility Notice (Perm)