BLDG (0306-142)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty o/perjury that | am licensed upUe pmv ixionao/
Chapter 8(commencing with Section 70000/Division unfthe Business and
Professionals Code, and nyLicense ieinfull force and effect.
License # L/v.o/asu ' Exp. Date .
2/� n'(
OWNER' BUILDER DECLARATION�
|omo�om�u�op�a�oxp�u���|amoemptfrom the Contractor's
License Law for mo'fdlowingreason:
. ( ) |, aaowner o/the pmporty, or my employees with wages aotheir sole
compensation, will do the work, and the structure isnot intendedxxoffered for
sale (Sov.ro*4. Business uProfessionals Cmu&). '
( ) |, as owner of the pmponu am exclusively contracting with noonood
oommotom to construct the project (Seo. 7044. epsmma & Professionals
Code). ^ .
() |omexempt under Section omPC.for this reason
omoignexumm'mwno,
.
WORKER'S COMPENSATION DECLARATION
` _
| hereby affirm under penalty of perjury one of the following declarations:
(>| have and will maintain ocertificate cxconsent mself-insure for wm,ko��~
oomponaution, as provided for by G0000n3700 of the Labor, Codo, for the
pdrfv,man000f the wmm�,which miopennnioissued.
�/ | have and maintain compensation i��mn�.aomq�m6 —
Svv8v 'of the Labor,Code, for the performance of the work for*which this
permit is issued. My workers' compensation insurance carrier.& poli6y.no. are:
Carrier S-[,4,yjr
Policy No.
(This section need not be completed if the permit valuation is for $100.00 or'less).
( ). I certify that in theperformance of the work,for which this permit is issu'ed,
I shall not employ any person in any manner so as to become subj6ct tothe
Workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Coc[6, I shall forthwith comply with tho'94. provisionA/
Applicant
Warning:, Failure to secure Workers' Compensation coveragd.is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1 00,000,,ih
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 sub ect to the conditions and restrictions set forth on his
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 applicaton agrees to, & shall, indemnify,
~ '~~ harmless^^e ~'y of ~~~~^'~' '~~^~~~' agents and ~'p~r"""
2. Any permit issued aou �a����application becomes -null and void if
work is not commenced wnxin 180 days from date of ionuonno of such
ponnn, or cessation oxwork for 180 days will subject permit mcancellation.
| certify that | have read this application and state that the above information io
oonom. | agree mcomply with an City, and State laws relating mthe building
construction,and hereby City menter upon
the 'mentioned
Si natum(Ownomgom) .
-.--BUILDING PERMIT.
DATE , VALUATION LOT'. TRACT
JOB SITE
ADDRESS
APN
-OWNEIR
CONTRACTOR DESIGNER EN61NEER
ROJ�QX 124
o4 08-7 5213
USE OF PERMIT
A TX (t F_TA1N1n40-/"0MB0
JUN 09
TA
-REST A
RECEIPT ]DATE
_FBY
NA ED
71-
INSP
_9PTOR
n
16114
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Final
Utility Notice (Perm)
COMMENTS: