AR (0203-153)LICENSED CONTRACTOR DECLARATION..I hereby aff iim under penalty of pe�jury`that l,am licensed under provisions ot.with Sectipg,,7000fof Division 3 of the Business and..-Pr6f6ssionals'Cocle,alind my1icen - se* is in full force and effect.ateLicense # Lic. ClassDate Signature of ContractorOWNER-BUILDER DECLARATIONI hereby affirm'bhder penalty of perjury that I am dempt from the Contractor'sLicense Law fo� i6e*folloWing- reason:'Is 1,, as.*bwner of the property,or my employe6s with wages as' their sole �,I'isale (Sed� , 4.1044, Business & Profes'sionals Code):. a�;:o I wh r of t6e' prolpe I �ty, am exclusively contracting with licensedcontractors . to. co�stru6t -the project (Sec. 7044, -'Business & ProfessionAI -am 6�emot under Section B&� G�f'diir this reasonDateWDRKER'S COMPENSATION DECLARATIONr,ker�by, - iirm' U . rider. penalty-, of. perjury one of'th6 following declarations:I haVd aHcl!wil 1'm�iriiain a certificate of consent to! slelf -insure for workers'c6mpensatio V1, �d for 15�, e8tion 3700 of the Labor Code, for thepermit i i6s� My- workers' compensation insurance carrier & policy no. are:er :Policy No.(This section'rieed not be completed.if*the permit valuation is for $100.00 or less).I certify iitat,ip"Ae perform iri'ce of the work for which this permit is issued,I shall not bm to become subject to the. ., ploy any person in anyi,manner so as.-wo*rkers' compensation laws of Califb'rnia, and agree that if I should become,,�u6j�ct to.'ihe-.W�rke��'.�6�l'pen�atioh'provisions�of Section 3700 of the 1_6bor-'oDate: Xpplica,htWarning: Fai.&6 to secure Workers" Compensation coverage is unlawful and',shall subject anaddition to the cost of compensation damages!as. provided for in Section 370�.'of the Labor Code, interest arfdatton)e,y, 's fee's,IMPORTANT Application is hereby rf4de to*the Director'of Building and Safetyfor a permit subject io t6e -conditions and restrictions set forth on his1. Each person upon whose behalf this application -is made & ekh;person atwhose request and for whose benefit work is performed under br pursuant to& hold harm I eS6. th'e';C ity of La Qu�irita'; its officers, agents and employees'iJed a" -d rel�ult of this. application becomes null and �oid it: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 cancel latiqn.:I certify that I have read this application and state that the above informationjscorrect. I agree to comply I with all City, and S , tatb laws relatin'g,!o the'buildingconstruction, and hereby authorize representatives,of this,City,.to enter upbhthe above -me ntione.d. p rope rtV for inspection purposes.Signature' (Own—e��Xa_&ntl' '011x/6—J
3 TRACT
ADDRESS
APN
OWNER
R.
2076
USE OF PERMIT
.00
V.
4TIO 4.34.00 SF [VI
J.
CITY
JPLAQ )4
FIN
k4, iFUF5 T
summmay
M�.Cfl"WAL FES -000-4216000,
420- 30.19
REC EIPT
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 d
O.K. to Wrap
Exhaust Fans
F.A.U.
Framing -O �.
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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