BLDG (0105-308)' JLICENSED CONTRACTORDECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 1 9 (commencing with Section 7000) of Division 3 of the Busin4ss and
my License is in full force and effect.
�uc�a # ' ~ uc��p Exp. Date
.
Contractor
Date' -9
of `
OWNER -BUILDER ' . DECLARATION
..
hereby affirm under penalty of perjury that |'amexempt from��oCom�om�e,
'L�emmLaw for the h��w�g�aoun: .' /
( ) |.aoowner of the pmpertyormyemployees with wages oatheir sole /
compensation, will do the work, and the structure is not mte"uau or offered for
sole (Sec. '---' Business --' Professionals Code). ^
m). |, as owner ox1he property,,am exclusively contracting with licensed
contmcmrs'm construct mo pn8om (Sec. 7044, Business u Pm�uuiono|u
' ` .
)ain- Section aaPC for this reason
'
Date -Signature of Owner
WORKER'S
' KER'S���P�m�/�l�N����ARATON ^ .
. ..
| hereby affirm under pon�� of perjury one of mo following d��o�n :
()| have and will maintain acertificate of consent mself-insure for workers'
compensation, provided for by Section 3700 o, the Labor CoUa'fo, the
performance of the work for which this permit is isgbe�'.
I have and will maintain workers'�6,ompensation insurance, as required by
Section 3700 of"tfi6.JC�borQ3cie, for the performance of the work for which this
permit is issuecl.�My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
!This section need not "" completed ii*the p'erm"`,=""""'''"'",*'kbo or.'Ie"ss). `
Certify that inthd performance of the work for which this pe.rmit.is issued,
,y any person in any manner so as to become subject to the
�vorkers' compe"nsation laws of California, and agree that if I should become
subject -to the workers' compensation provisions of Section 3700 of the Labor
'Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: to secure wmmvm' Compensation coverage is unlawful and
shall subject an.employer to criminal penalties and civil fin eis up to $100,000, in
iddition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT, Application iohereby made tvthe Director o/Building and Safety
for o permit subject to the conditions and restrictions set forth on his
application. .
1. Each person upon whose behalf this a . ppncamon is mouo & each person at
whose request ond.forwhose benefit work ioperformed under orpursuant to
,
any permit issued aoaresult tfthis appUcaton agrees to, &shaU. indemnify
.& hold harmless the City n/La Quinto, its officers, agents and employees.
^o.Any permit issued aoaresult of this application becomes null and void if
work is not oummovnou within 180 doxa from dsuo o/ issuance of such
.'dorTit,.uruaooau|on ofwork for 180 days will subject permit to cancellation.
"|oerlKy�'a'tUh�veread this application and state that the above information is
correct. | agree mcomply with all City, and State laws relating mthe building
m?nstmminn, and hereby authorize representatives of this City to enter upon
the above-m�nUonuUpmponyfor inopo�ionpurposes.
,
.
_"-_-A
It
M
DAfE VALUATION LOT
JOB SITE
Do
APN
.wet1w AWNIVA KAVATZIRD
OWNER
CONTRACTOR DESIGNER ENGINEER.
uk Qump. CA 922,S3
LA QT,7WrkX CA 9225 3'
(166)564.6119 C131A
USE OF PERMIT
57T. W001) FENCE 87,00 LF
F11113"MA:= COST OF CONSDOWRON
666,43,
CONOTRUCTION FEE I q] .000-4.3 &()00
RAY 2 5 2001
CITY Or LAQ-UNINTA
TOTAL FERMW r"IM'S DUE NOW
WA)
RECEIPT
DATE
BY DATE FifiALPID
INSPECTOR
It
M
4r
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs _ _ _
Footingsl
Bond Beam
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
J '-A
Final f/ O l LY
PLUMBING APPROVALS ��•(((
Underground Plbg. Test
Gas Piping
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: