BELC2015-0023LICENSED CONTRACTOR'S DECLARATION.
I hereby affirm under penalty of perjury that I am,licerised under provisions of Chapter
9 (commencing with Section 7000) of Division 3 o the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.::CONV:140528101254135646
Date: _ Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I' am exempt from.the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve; demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031:5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).;
)Mas owner of the property, or my employees with wages as their sole '
compensation, will do the work, and the structure isnot intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contractors' State'License Law does not
apply to an owner of property who builds or improves thereon,,and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, -however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden.of proving that
he orshe did not build or improve for the -purpose of'sale.).
8 -Alas owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'_
State License Law does not apply to an owner off property who builds or improves
thereon; and who contracts for the projects with a contractors) licensed pursuant to
the Contractors'State License Law.).
cpm exempt under Sec. B.&P.C. for this reason
Date Owner:/
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for.
the performance of the work for which this permit is issued (Sec. 3097; Civ. C.).
Lender's
Lender's
WORKER'S COMPENSATION DECLARATION
I hereby.affirm under penalry.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.
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 and policy number are:
Carrier: Policy Number:'-.,
� certify that in the performance,of the.work for which this permit is issued, I
s. ploy any person.in any manner so as to become subject to the workers'
compensatioMaws 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
com�_pllPy with those provisions.
DA' 0 9 / Applicant`
WARNING: FAILURE TO SECURE'WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER'TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the'Building Official for a permit subject to
the"conditions and restrictions set forth on this 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 , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 180days 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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the above
mentioned property for inspection purposes.
ALVazj
Dat Z Signature (Applicant or Agent). i
VOICE(760) 777-7125
78-495 CALLE TAMPICO
D -`
.
FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253
COMMUNITY;DEVELOPMENT;DEPARTMENTINSPECTIONS
(760) 777-7153
BUILDING PERMIT .
Date: 3/27/2015
Application Number:
BELC2015-0023.
Owner:
Property Address:
53565 AVENIDATOBREGON
PORFIRIO MENDOZA
APN:
774114013
AVENIDA OBREGON
g
Application Description:
MENDOZA REPLACE ELECTRICAL METER
LA QUINTA, CA 92253
Property Zoning:
QLQ
N zo
Application Valuation:
$300.00.W
So
LJ
Applicant:
Contractor:
-w
Q �
v
PORFIRIO MENDOZA
PORFIRIO MENDOZA
AVENIDA OBREGON
AVENIDA OBREGON
��
LA QUINTA, CA 92253
LA,QUINTA, CA 92253
o
U
(760)238-0960
-----------------------------------------------
-------------------------
LIc. No.::CONV:14OS28101254135646
---------------------
LICENSED CONTRACTOR'S DECLARATION.
I hereby affirm under penalty of perjury that I am,licerised under provisions of Chapter
9 (commencing with Section 7000) of Division 3 o the Business and Professions Code,
and my License is in full force and effect.
License Class: License No.::CONV:140528101254135646
Date: _ Contractor:
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I' am exempt from.the Contractor's State
License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve; demolish, or repair
any structure, prior to its issuance, also requires the applicant for the permit to file a
signed statement that he or she is licensed pursuant to the provisions of the
Contractor's State License Law (Chapter 9 (commencing with Section 7000) of Division 3
of the Business and Professions Code) or that he or she is exempt therefrom and the
basis for the alleged exemption. Any violation of Section 7031:5 by any applicant for a
permit subjects the applicant to a civil penalty of not more than five hundred dollars
($500).;
)Mas owner of the property, or my employees with wages as their sole '
compensation, will do the work, and the structure isnot intended or offered for sale.
(Sec. 7044, Business and Professions Code: The Contractors' State'License Law does not
apply to an owner of property who builds or improves thereon,,and who does the work
himself or herself through his or her own employees, provided that the improvements
are not intended or offered for sale. If, -however, the building or improvement is sold
within one year of completion, the owner -builder will have the burden.of proving that
he orshe did not build or improve for the -purpose of'sale.).
8 -Alas owner of the property, am exclusively contracting with licensed contractors
to construct the project. (Sec. 7044, Business and Professions Code: The Contractors'_
State License Law does not apply to an owner off property who builds or improves
thereon; and who contracts for the projects with a contractors) licensed pursuant to
the Contractors'State License Law.).
cpm exempt under Sec. B.&P.C. for this reason
Date Owner:/
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for.
the performance of the work for which this permit is issued (Sec. 3097; Civ. C.).
Lender's
Lender's
WORKER'S COMPENSATION DECLARATION
I hereby.affirm under penalry.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.
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 and policy number are:
Carrier: Policy Number:'-.,
� certify that in the performance,of the.work for which this permit is issued, I
s. ploy any person.in any manner so as to become subject to the workers'
compensatioMaws 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
com�_pllPy with those provisions.
DA' 0 9 / Applicant`
WARNING: FAILURE TO SECURE'WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,
AND SHALL SUBJECT AN EMPLOYER'TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($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.
APPLICANT ACKNOWLEDGEMENT
IMPORTANT: Application is hereby made to the'Building Official for a permit subject to
the"conditions and restrictions set forth on this 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 , the owner, and the applicant, each agrees to, and
shall defend, indemnify and hold harmless the City of La Quinta, its officers, agents, and
employees for any act or omission related to the work being performed under or
following issuance of this permit.
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 180days 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 county ordinances and state laws relating to building
construction, and hereby authorize representatives of this city to enter upon the above
mentioned property for inspection purposes.
ALVazj
Dat Z Signature (Applicant or Agent). i
R— MAM<`"� Val
ggy; ti � i:1a`� V 1 B Q G'I I+I CQ A§ 3 `� a .� � �..
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nen
Description: MENDOZA REPLACE ELECTRICAL METER
Type: ELECTRICALSubtype:
Status: -'UNDER REVIEW
Applied: 3%27/2015 SKH
Approved:
Parcel No: 774114013 Site Address: S3565-AVENIDA OBREGON LA QUINTA,CA 92253
Subdivision: SANTA.CARMELITA AT VALE LA QUINTA Block: 189
Lot: 3
Issued:
UNIT 19
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Lot Sq.Ft: 0 Building Sq Ft: 0
Zoning:
Finaled:
Valuation- $300.00. Occupancy Type:
'Construction Type:
Expired:
No. Buildings ,0 • ; No Stories: 0
No. Unites: 0
.-LDING CODES.
Details: ELECTRICAL METER CHANGE OUT:2013 CALIEORNIA g:.Ul
BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00
.Total Paid forBU.ILDING STANDARDS ADMINISTRATION
BSA: $1.00 $0.00
Printed: Friday, March 27, 2015 1:19.:05 PM 1 of 2
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BSAS SB1473 FEE 101-0000-20306 0 $1.00 $0.00
.Total Paid forBU.ILDING STANDARDS ADMINISTRATION
BSA: $1.00 $0.00
Printed: Friday, March 27, 2015 1:19.:05 PM 1 of 2
SYSTEMS
DESCRIPTIONS
ACCOUNT
QTY
AMOUNT _
PAID
PAID DATE
RECEIPT #
CHECK #
METHOD
PAID BY
CLTD
BY:
SERVICES
101-0000-42403
0
$24.17
$0.00
SERVICES PC
101-0000-42403
0
$12.09
$0.00
Total Paid for ELECTRICAL: $36.26 $0.00
PERMIT ISSUANCE
101-0000-42404
0
$91.85
$0.00
Total Paid for PERMIT ISSUANCE: $91.85 $0.00
TOTALS:i0
INSPECTIONS
SEQID INSPECTION TYPE INSPECTOR SCHEDULED COMPLETED
DATE DATE
RESULT REMARKS NOTES
ELECTRICAL FINAL" BLD
PARENT PROJECTS
Printed: Friday, March 27, 2015 1:19:05 PM 2 of 2
SYSTEMS
78-495 CALLE TAMPICO
LA QUINTA, CALIFORNIA 92253
{
"J
BUILDING & SAFETY DEPARTMENT
(760) 777-7012
FAX (760) 777-7011
Considering Becoming. an Owner -Builder?
Important information you need to know BEFORE pulling your permit! .
The term "Owner -Builder" can mean three different things:
"Owner as Worker", "Owner as. Contractor" or "Owner as Employer"
Understand each has Benefits or Risk, and it is possible to combine them!
Wring a California Licensed Contractor means you do not.personally perform any of the construction work, the permit is not taken
out i your name, you are not personally responsible for the constru'ctiorrand.you are not an Owner -Builder. Instead, you become a
"Cu o`mer" and California law provides you the benefit of protection from poor workmanship. failure to finish the job and financial
riskue to worker injury.
Benefit/Risk: Highest Benefits and the.Least'amount of Risk
Owner -as -Worker is a type of Owner -Builder where .you personally perform the construction work, the permit is taken out in your
name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You
benefit by not paying others to perform this work for you and your risk depends:on your, own ability to complete the job successfully.
BeneSt/Risk: Possible Benefit with Low Financial Risk
Owner -as -Contractor is a type ofOwner=Builder wh6re.you.personally Act.. as.yoiir.own.General. Contractor, the permit is taken out in
your name and you hire California licensed: sub-conlractois to.perform,portioits of tlrc construction Work. WARNING: The benefit of
protection provided by law when you hire: only California licensed sub -con' racI0.M can..forn IQ. serious financial risk if you hue
._^ unlicensed contractors to.perform
Benefit/Risk: Possible Benefit and Significant Financial Risk
Owner -as -Employer is a type of Owner -Builder where you pay any unlicensed individual to perform an i., construction. work valued at
more than $500.00, the permit is taken out in your name and you are personally. responsible for. their employment requirements.
supervision, performance, safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial
risk if you fail to deduct pgvroll tares or provide workers compensation insurance for each worker.
Benefit/Risk: Possible Ilcnerii. with Significant Financial Risk
A _
(Health and Safety Code Section 99827) The California Legislature declares an "urgent and statewide
public interest in assuring" that contractors comply with Contractors' License Law. Business and
Professions Code and Workers' Compensation Insurance requirements to ensure property owners are
informed about, and protected from the following when improving their property as Owner -Builders:
Fraudulent representations • Liability for worker's injuries • Liability for material and labor costs unpaid by
contractors • Licensing requirements • Employers tax liabilities
1
Over 20,000 consumer complaints are filed each year. Many complaints relate to owneribuilder projects
and include workmanship and workers' compensation issues Homeowners suffer financial harm due to
defective workmanship and injured employees.
Following are alarming examples of what has occurred with Owner -Builder permits:
Example 1: Homeowner received insurance money to rebuild bumed=down home.
• Owner/Builder permit pulled to rebuild structure.
= Unlicensed contractor built substandard structure — must be torn down and replaced.
• Estimated financial injury is $225,000.
• Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of
the year.
Example 2: Brother-in-law had active license but filed an exemption from Workers Comp.
■ Owner -Builder hires brother-in-law to install a new roof.
• Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and
remains in a coma to this day.
• The Owner -Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for
benefits paid to the injured worker.
Example 3: Employee of contractor without Workers Comp is hired by Owner -Builder to install septic
system and suffers injury that results in permanent disability.
■ The Owner -Builder did not have a homeowner's insurance policy on the house against which to submit
a claim.
• The Owner -Builder is now a defendant in.a lawsuit for reimbursement for benefits paid to the injured
worker.
Did you know — unlicensed persons frequently have the property owner obtain an "Owner -Builder" building
permit which erroneously implies that the property owner is providing his or her own labor and material
personally?
Did you know — your homeowner's insurance may not provide coverage for injuries sustained on your
property by an unlicensed contractor and his/her employees?
Did you know — if you are considered an "employer" under state and federal law, you must register with
the state, and federal government, withhold payroll taxes, provide workers compensation and disability
insurance and contribute to unemployment compensation for each "employee"?
Did you know — that if you fail to abide by these laws you may be subjected to serious financial risk?
OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR
YOUR CONSTRUCTION PERMIT
s,u
BUILDING &,_SAFETY.DEPARTMENT
78-495 CALLS TAMPICO (760) 777-7012
LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7011
1PROPERTY O •r T. 1 R. � C A C% It l
Disclosures & Forms for Omer-Baliders Applying for Construction Permits
DWORMAT— 1 NOTICE TO PROPERTY OWNI IR .
Dear Property Owner.
An application ;for a,building::peruut :has been submitted...' }roar name listing yourself.as the builder of the. property
improxements.spacified at t5.2, S �. -2 n/. . (,�. ��.IN-i A .� C �� o1Z25 3
. cN1,r)/� =leo
We are providing you with an Owner -Builder AckoLowledgient and inforruatron;Yetrfieation Form.to. make you awaw of.your
respoasrbililies,and possible risk-yowmay..-incur.by haiving:this permit isstsodJn.your.tjme as.tbe
Ower -Builder... We.srdl not Issue x buiildLrg.pcttutit umtil-:y" hsve'.rexd; inti*# your•,understaading of eack' rOvicion,
signed, and returned this form to us at our official address indicated. An agent of the owner. cannot execute .this _notice ,
unless you, the property owner, obtain the prior approval of the permitting authority.
a. I. 1 .understand a icquent, practice of unlicensed persons is to have tlse iprolierty owner, obtain an "O:wncr-Duildcr"
building perriiit drat errono4i�rsly:impliesrthat the propertyowner is.providing:liis or,lter.own labor; and. mate
ersous�Ily
an ONVncr-Builder may be:lield liable and subject to serious finaneiatrisk Eor any'rnjunes:sustaincd.by An unlicetiseif person
and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those
injuries. I am willfully acting as an Owner -Builder andam aware of the limits of my insmance,coveragc for injuries to workers
on my property.
J2. I understand building permits are not required to be signed by property owners unless they are responsible for the
construction and are not hiring acensed Contractor to assume this responsibility.
3. I understand as an "Owner -builder" I amt -the responsible party of recdrd on the permi1 understand that I may protect
myself from potential financial risk by hiring a Licensed Contractor and having•the permit filed in his or her name instead of my
own. .
lf,v 4. I understand Contractors are required bylaw to be licensed and bonded in California and to list their license numbers on
permits and contracts.
VILtA5. I understand if I employ or otherwise engage any persons,' other than California licensed Contractors, and the total value
of my construction is at least Eve hundred dollars ($500), including labor and materials, I_ may be considered an "employer"
under state and federal law_
ice: I understand if I am considered an ."employer"` under state -and federal law, I must register with the state and federal
-.--government;-withhold-payroll-taxes; provide=workers'=compensation`disability-uzsurauce,--and-coutnbtite-to-unemployment---------
compensation for each "employee." I also understand my failure to abide by _these laws may subject me to serious financial
risk.
1 ',04. I understand under California.Contractors' State License Law, an Owner -Builder who builds single-family residential
structures cannot legally build them with the intent to offer them for, sale, unless all work is performed by licensed
subcontractors and the number of structures does not exceed four within any, calendar year, or all of the work is performed
under contract with a licensed general building Contractor.
P, $. I tatderstand ac an Owner -Builder if I sell the property for which this pertnit is issued, I may be he'd liable. for any
financial oC persoaal,:iacics sustained by any subsequent owner(s) that result from any latent construction defects in the
wofitrnaiishi�i cir'iniatcrials.
E./v9. 1 understand I may obtain more information regarding my obligations as an "emlibycr" (i9n1 tiro 1ntt�txtbl Ttcvcnue
Service, the United States Small Business Administration, the California Departruent of Benefit Payments, and the California
Division of Industrial Accidents. I also understand 1.may contacttlic California Contractors' State License Boaro at t-
800-321-CSLB (2752) or www.eslb.ca.gov for more information about licensed contractors.
10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the
party legally XA financially responsible .for proposed cons etton activity the following address:
i✓+��►2l�,�2ct-,ole} !,A�►':-c A 2.253
PI Eivi 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity. I will abide by all
applicable laws and requirements that govern Owner-Builderi as well as employers.
1P,jE�A.A 12. I agree to notify the issuer of this form immediately of nay additions, deletions, or changes to *ny of the infotm&tiois I
have provided on this form Licensed contractors are regulated by taws designed to protect the public. If you contract with
someone who'does not have a tieense, the Contractors' State License Board may be unable to assist you with any Snaneial loss
you may sustain as a result of a complaint Your only remedy against unlicensed Contractors may be iwavil court- It is also
important for you tounderstand that if an unlicensed Contractor or employee of that individual or firm is injured wtrile working
on your property, you may be herd tittiilu':for:da ci;: If you of lain ri pcmut as tg bim Contract ors,
you will be Ne for v ` . ` ... .
y rrspons exriyu>� or•not tlStYttiis of their workers'
compensation i 1su anoc coverage.
Before it building permit can be issued, this form must be completed and signed by the property owner and returned to
the agency responsible for issui tg:tw.per=iL Nola: A copy of tkc•propert owner's diiver'y�tcoresej farm +i ns or
other verification acceptable to the agency is required to be presented when tkr permit is issued. to Verify the prvp"
owner's signature.
Signature ofpropertyown o 1J � 11G Date: �S
Note. The following Authorization Form is required to be completed by the property owner only when designating
an agent of the property owner to apply for a construction permit for the Owner -Builder.
AUTHORIZAtT.ON OF AGEW TO ACT ON PROPERTY OWNER'S -BEHALF
Excluding the Notice to Property Owner, the execution of which I understandds my personal responsibility, I hereby authorize
the following persons) to act as my agents) to apply for, sign, and file the documents necessary to obtain an Owner -Builder
Permit for my project_
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above
information and certify_ its accuracy. Note�A copy ojlhe owner's driver's license,form_nolarization, or other verification
acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature.
Property Owner's Signa J r.Date:: D
Bin #
City of La -.Quinta
Building 8T Safety Division
P.O. Box -1504,78-495 Calle Tampico
La Quinta, CA 92253 - ('760) 777-7012.
Building Permit Application and Tracking Sheet
Permit #
Project Address: _� _ N\
Owner's Name: v� �V—N
A. P. Number:
Address: �3 SLS utN2c(�o
Legal Description:
City, ST, Zip: 2,
Contractor•
.
,Tele P hone: 6 2 m O �6 c7
Address:
Project Description:
City, ST, Zip:
_N
A . L., _.a-k� — _L
Telephone:
e P
State Lic. # :
City Lic.
Arch., Engr., Designer:
Address:
City., ST, Zip:
Telephone:
Cori tr ucti n TYancY
: Occupancy:
Pe. :
State Lic. #•
Project type �circle.one : New Add'n Alter Repair Demo
Name of Contact Person:
Sq. Ft.:
# Stories:.
# Units:
Telephone # of Contact Person:
Estimated, Value of Project: 3�
'APPLICANT: DO NOT WRITE BELOW THIS LINE
k
Submittal
Req'd
Recd
TRAC04P ,
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed, ready for corrections'
'Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2".,Review, ready for corrections/issue
Electrical
Subcontactor List
Called.Contact Person
Plumbing
Grant Deed
Plans picked up
S.M:I.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date.of permit issue
School Fees
Total Permit Fees
. CITY. OFLA �� ��U KU���-�� «��0��
^ .
JOB ADDRESS PERMIT. NUMBER OWNER -BUILDER
This form shall be posted on the job with the Building Inspection. Card at all times in a conspicuous place.. Only persons appearing on this list -or their employees are authorized to work
on -this job. Any changes tnthis list must be approvedby the Building Division prior to commencement,of work. Failure tocomply will result i9astoppage ofwork and/or the voidanoo.
of building