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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
,D�1a�ter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force an • effect.
License # - Lia Class Exp. Date
W -421S C35 MOW
ate �Y"~ Vii[,"'C� Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of pertury,that I am exempt from the Contractor's
License Law for the following. reason:
( ) I, as owner of the property, or my. employees with .wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ') I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. •7044., Business & Professionals
Code).
O Lam exempt under Section B&P.C.-for this'reason .
'.Date Signature of Owner;
WORKER'S COMPENSATION DECLARATION
I .hereby affirm under penalty of perjury one of the following declarations:
O 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 & policy no. are:
Carrier 77 ffFt Policy No. Y -
67
(This section need not be completed if the permit valuation is for $100.0& or less).
() I certify that in the performance of the work for which this permit is issued,
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I shall, not employ any person in any manner so as to become. subject to the
workers' compensation laws of .California,/anb agree that, if I should become
subject to the workers', compensation provisions of Section 3700 of the Labor'
Aode, I shall forthwith comply with those provisions.
Date:*i ✓ K A' pplicant
Warning:, Failure to secure Workers' Compensation coverage is unlawful'and
'shall subject an employer to criminal penalties and; civil finesup to';$b00;000, in
addition:to the cost. of compensation, damages as provided for In Section 3706
� 6
of the Labor Code, interest. and attorney's
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 at, F.
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
& hold harmless the City of La Quintal its officers, agents and employees...=
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 180 days will subject permit to cancellation' 1,
,ass`
I certitWthat I have read this application and state that the above information is
corr et. I agree -to comply with all City, and State laws relating to the building
co ruction, and hereby authorize representatives of thio- City to enter upon
th above mentioned property for inspection purposes .
Signature (Owner/Agent) Y 1.i fi Date rf a tk
I
BUILDING PERMIT' PERMIT# CONTROL#
BUILDING PERMIT NI '5
t,�e�<���n�ts � 7 4
DATE raVALUATION�r�1} �� LOT TRACT
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ADDRESS
JAPN
OWNER
CONTRACTOR / DESIGNER / ENGINEER '
Cir 7'� ORN,11A. �'ii.,•ivV �d PAS 1. �, ea
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80-231 M131 -7,101N, .. ••
74- 725 J 0I�V:�1 J,�X� VE, #A.
CA 92253
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(Ritifi) } i1b9t}(1 CAL# 'a55
USE OF PERMIT
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1997-t-6- p � Fi.li.:t lid k}af•LS A T :s VE, NOW
RECEIPT -7',"' DATE
BY ' -"•✓
DATE FINALED
INSPECTOR
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
steet>
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 _
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: