0201-074 (MISC)79698 Arnold Palmer
' LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT"
N I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9(commencing with Section 7000)of Division 3 of the Business and t
DATE ( VALUATION LOT 02.01-074 TRACT
04 W Professionals Code,and my License is in full force and effect. //3 {J v` $20A0
C v M License# Lic.Class Exp.Date roe SITE
p APN
r. 733152 B , t03!3 2C ADDRESS ARNOLD PA1.1 KR
Z Date 2 11 : ' Signature of Contractor v ' l +I n OWNER CONTRACTOR/DESIGNER/EN INEER
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J U OWNER-BUILDER DECLARATION PGA W0T RnIDENT A4L AS80C1Kff0X DE,[ MAR PAC IRC C1)".1` MI AL COW17RACrOR S
H LUI hereby affirm under penalty of perjury that I am exempt from the Contractor's PICY SOX]( ,() 2-5'a 3 k3 J(JT EI CUA,'3r 1RC11 jpiy 13?7- 250
to License Law for the following reason: LA QIJ[H'fA CA 9,x",2.53 CA; DI"'LAY 111 WKA CA 92.007
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (76(Y)564-9500 CS10 5823
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals MT3C'F I'1.N.E.OU.i
Code).
C () I am exempt under Section B&P.C.for this reason 13j111,01NO 17. 79•iXP , Y9•dtr8,79-ti9t l•dilT•EIOLUTI't'd41tX
C\IN Date Signature of Owner STRUCTURAL NiODIVIC,ATIONS
rn
a Z WORKER'S COMPENSATION DECLARATION
o cr I hereby affirm under penalty of perjury one of the following declarations:
Lo H p ( ) 1 have and will maintain a certificate of consent to self-insure for workers' VALUATION L1QUO,pi 1„
X Wcompensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q perfgrmance of the work for which this permit is issued.
Q I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d I- permit is Issued. My workers' compensation insurance carrier & policy no. are:
z Carrier Policy No.
co 5ZA`,t'1 L1Nfa bab01 UN1T0►ft d l s
C3 P !lxb'13:M[ATED COf r OF CON 17RI MOp 2(),()ti(?.W
g (This section need not be completed if the permit valuation is for$100.00 or less). R M 1171!''6'.SII MIARY
( ) I certify that in the performance of the work for which this permit is issued, CONSTRUCTRYS".E 101.000-416.000 $207100
1 shall not employ any person in any manner so as to become subject to the STPIOAKI MOTIUM PEP.•MID 101-00()-.241-00() _ $3.00
workers' compensation laws of California, and agree that if I should become
subject to the workers'compensation provisions of Section 3700 of the Labor
j .
Code,I s)iall fghhwith comply with those.provisioris.r• / }.
Date: Applicant—
Warning:
pplicant Warning: Failure to secure Workers'Compensation coverage is unlawful and f
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 811E TOTAL CON;fRT1(TT10H JWD Til AP1 eXF!'C".3C
2,US1,(D(1
\ any permit issued as a result of this applicaton agrees to,&shall,Indemnify LOS InMS (f tt0
AVip & hold harmless the City of La Oulnta, Its officers, agents and employees.
ILL
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 TOTAL PERAW F100M.U.NOW
permit,or cessation of work for 180 days will subject permit to cancellation, r I IIIIIII VIII III VIII IIII
1 certify that I have read this application and state that the above Information is 12
• correct. I agree to comply with all City, and State laws relating to the building IE
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
RECEIPT DA BY DATE 7 D, INSPECTO
Signature (Owner/Agent) '• r' ti f Date - l ! Z
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.K to Wrap F.A.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final POOLS - SPAS
BLOCKWALL'APP' ROVA,6 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
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 i
Gas Test
Appliances
Final
i
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service i
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp,use of Power
i
Final
tJtilily Notice(Penn)