0404-071 (ELEC) U) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#�-07�
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE to6VALUATION i LOT TRACT
04 W Professionals Code,and my License is in full force and effect. fit ��9,f•
O =) License# Lic.Class Exp.Date9/n JOB SITE
r 6;7R 74�' I.C:%f Y -6ADDRESS (41-050,4�-1r'EN1111�15 1APNZ r- fDate�` ��� Y•'� Signature of ContractOWNER CONTRACTOR/DESIGNER/EN INEER
� F- C) OWNER-BUILDER DECLARATION CORAL 01yrJ0141'7-"C'Z'' `SPAT{_fO,9 C;'�3A7.�7Ti.UC'.I'Tf71+i
r PO BOX 1716 79.295 RAN0401.,A QVI�tTADR.
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
a LA QtT31~I'1A CA 92253 LA QItNTA CA 92253
U) License Law for the following reason:
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760',1771-194 3, 031,4 29961
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 MWTRMA„
contractors to construct the project (Sec. 7044, Business & Professionals
Code). COMM,MOUNTAIN S1'1'tr F1.VCTR1CAJ,it QVICL;"- Q 00A,,-r7PIS0v)
ce) () I am exempt under Section , B&P.C.for this reason
LO
N Date Signature of Owner
ON
0)
a Q WORKER'S COMPENSATION DECLARATION
QZ I hereby affirm under penalty of perjury one of the following declarations: V A 1,t31�1101� 13,7SD.£tf3 4 r9
F- p ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m 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 rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
IRt Z Carrier STATE KIND Policy No. 046-733A-A'003 ESIMIXI`[M C09J,or Cc"3.1VMU+C"I'ION I?'7'50.0o
J (This section need not be completed if the permit valuation is for$100.00 or less). L0,FMIUM,FER 10 1-MUAM 000 $90.00
( ) 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,provi'§i6ns of Section 3700 of the Labor
Code, I shall forthwithFcomply with those provisions.
�Da'te: Applicant f
s 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 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 gO1',+_T'rAL CC.7N:
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&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
Final
Final 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
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
COMMENTS:
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
Final
Utility Notice(Perm)