9806-100 (BLCK)^ LICENSED CONTRACTOR DE61LARATOm '
| ho,e ; affiim''under penalty of mbrjvry that | am licensed under provisions o,
Chapter 9 (commencing with Section 7000) of Division o of the Business d
Professionals Code, and my License is in full force and effect/
License # Lic. Class I Exp. Date
64toe Signature of Cor tract-'
OWNER -BUILDER DECLARATION
| hereby affirm under penalty cxperjury that | am exempt from the Contractor's
License Law for the following reason:
( ) |, as owner ofthe property, or my employees with wages ootheir sole
compensation, will dothe work, and the structure ionot intended o,offered for
sale (Gou.7u44.Business uProfessionals oouo).
( ) |, as owner of the property, am exclusively contracting with licensed
oontmoms to construct the project (Sec. 7044. 8uoinoao & Professionals
Code).
() |amexempt under Soonon.axeo. for this reason
_________
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
| hereby affirm undo, penalty of perjury one of the following uoo|onmions
()| have and will maintain acertificate o»consent mself-insure for workers'
ooms�tti n. as provided for by Section o7nocxthe Labor Code, for the
_8pm»,man000fthe work for which this permit iuissued.
| have and will maintain workers' compensation insurance, aorequired uy
Section 3700 of the Labor Code, for the pomo,munoo of the work for which this
permit is issued. myworkers' compensation insurance carrier & policy no. are:
Carrer Policy No.
83,�[81"[ND, 442402
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) | certify that inthe performance o,the work for which this permit ioissued,
| axan not employ any person inany manner 0000mbecome subject mthe
workers' compensation laws mCalifornia, and agree that if| should become
subject tothe workers' compensation provisions ofSection o7000fthe Labor
Code, | shall forthwith comply with those provisions.
oaoo:---------- Applicant
Warning: Failure msecure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition mthe cost nfcompensation, damages aoprovided for inSection o7os
of the Labor Code, interest and attorney's fees.
IMPORTANT Application iohereby made tothe Director o,Building and Safety
for u permit subject to the conditions and restrictions set forth on his
application.
1.Each person upon whose behalf this application iomade & each person ou
whose request and for whose benefit work ioperformed under orpursuant m
any permit issued aua result of thieopp|inamn agrees to, & ohun. indemnify
8hold harmless the City ovLaQvinoa. its offinom, agents and employees.
2. Any pannh issued axa result ovthis application becomes nun and void if
work is not commenced within 180 days from dam o/ issuance of such
permit, or cessation of work«or 18odays will subject permit to cancellation.
I certify that I have read this application and ata/te that the above information is
correct. I agree to comply with all City, and,'State laws relating to the building
construction, and hereby But I hori�ie representatives of this City to enter upon
the above- me ntioine� prop6rtyfof nspec6on purposes
BUILDING PERMIT'
DATE VALUATION
611 /93 LOT TRACT 7925 A
JOB SITE APN
ADDRESS 53-280 AVENWA ORREGON
OWNER CONTRACTOR/ DESIGNER /ENGINEER
PO BOX 13287 PC) BOX 13287
.(760)771-5571 CBL* 3028
USE OF PERMIT
3 A. W1641 REN W, iql 4CIT STD
' EeSTIDIMX11.111DCOST 0F
PERMIT FEE AMMAR%`
C0NmTRiCTPONYK8 110]-0N)-4184*0 $2|(0
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SUW�YY)"8/.rON8'T'R|m7DONAND 9IA'N(]HGCK �l1IN
LESS PRE -PAID FETS. SO.00
T0TA I.PFR N1 IT F F R44K)0F, NNVV I V,D.00
RECEIPT D TE ey DATE FINALED INSPECTOR
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INSPECTION RECORD
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.IC 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam �d'�
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final
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
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
r
Final
Utility Notice (Perm)
COMMENTS: