0011210 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp..Date
Date i ,f�!/; Signature of Contractor
OWNER -BUILDER DECLARATION ;
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) .,1, 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).
( .)
1, -as owner of the.property, am exclusively contracting with licensed
contractors to construct the 'project (Sec. 7044,. Business & ' Professionals
Code). ,
O I am exempt under Section B&P.C. for this reason
Date ' ,Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm underi penalty. of perjury .one .of the following.declarations:
() 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:
CarrierPolicy No.'
001A)EN. YAGLE rags, NWC-s�aart8.o
(This section need not be completed if the permit valuation Is. for $100.00 or less):
( ) 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 provisions -of Section 3700 of the Labor
Code, I shall forth{ ith comply with'those provisions.
/fir?V ir
Date: i' �JApPlicant 9, �•i l; J-��� �41J
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subjecfan 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
whose request and for whose benefit work is performedpursuant. to
any permit issued as a result'of this applicaton,agrees to, & shall, indemnify
& hold harmless the City of. La Writa, 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.
I certify that I'Fiave read this application and state that the above information is
correct. I agree to comply with all City, and State laws rebating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.-
Signature
urposes. Signature (Owner/Agent)''�P4%l-�lf%j1: Date1
BUILDING PERMIT PERMIT#
DATE(( VALUATION. LOT A�3-x.33 TRACT
*3 VAMM .69 27519
JOB SITE f +
APN
ADDRESS 79-43.0 AP1AbSE0 D L RXY
><6C4•� �8t'iR �3�►
OWNER
CONT(R�AwC�TpORg/y`D;E+{SIIG�NJEER,./�E�NyGIINNE�ER�
yy�y�y q� �y�y �y/�7��p�gyp�a r�ry
4WL'nGViVR1 Ir.LIowr.� 4:.�.lIWAIRl.W6V.1,�d.L`a -
�p �y�x, {�
'4{.ciV YRY 4.Si.1,J�i"F.A`-U, Ar�{.A'tLMU.4r.11.0
1535.30, WDOIkRg1 T, Sr.,Ms, 0200
1133 30. V, M"32v,k'sT. six X200
SAN B:lyRNARx.INO CA 99/108
SMBEWARDWO CA 9?A08
(905)381.6m., mm mo
USE OF PERMIT
'OLE 1FAM.•1t OWE%IMOr
SM LOT 69 .PLAN Sdc' PPAMI DOF-moi NCY;lNCLUM MOCK
WAMA001, -7516 PLANt"1RliCK PU .471?DUCTi 1014 FOR ki UL't'1►'LE
ISSUK14CE OF :Uk'�. X PLKIgTY'PE
TRACT CONOTRUCTION 2,068.00 Sr.
FORC"A.I'IO 448.00 HF
EiMIAT9'.I] COST OF COIN�+`3'W-1110YI
117X46.09. .
CONSTRUCTION YES 101-000-418.000
PLAN C14- CKiaE fol-Glt1{;�t3Si-41� fIr4G.(t=
MECHANICAL M 101 �000,421.00Q Q58;�4
r LVIN41,61 0 WOR' 101.060.4119.000
STIT.OW MOTION! PRE - W010 1.. tf l -000-241-000
CikA1U040 FEE.. 10..1-000!--IMS-000.t2a.0�
DEil•I°LO PPM IMPACT FEE
Liv 1' :C'�-w ma., C.;
$0.00
'f MAL MMMEM.-IN DIOR NOW
RECEIPTDIE
, �+
BY f f
DATE FINALED
INSPECTOR '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
ZAL-e ay'.e{—
Underground Ducts
Forms & FootingsDucts
Slab Grade
j�o� �'�d
Return Air
Steel
I
Combustion Air
Roof Deck
Z 1Z— �F
Exhaust Fans
O.K. to Wrap
12_f
F.A.U.
Framing
(ZZ CQVOay--
Compressor
Insulation
S'� e��b�G
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
POOL
AS
BLOCKWAL y A PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
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
Z,kQ
Pool Cover
Sewer Connection
_
�Lq
Encapsulation
Gas Piping
Gas Test
3
S�
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APAROVALS
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
s
Final
Utility Notice (Perm)
05/25/2001 FRI 11:34 FAX
Z 004
IC -1
INSULATI01 CERTIFICATE
79- 0 PASEO DEL RVLA
OUIhTA
Number and Street
City
27519 X69'
R ;aside
Tract No Lot Number
Coun
Description .►f installation
1 ROOF
Brand Name
Materia_
7emnal Resistance (R -Value)
Thickness inc i -s}
2 CEILING
Batt or Blanke Type BATT
Brand NameCERTXNTEED
R-38
Thickness(in r 'as 12
Thermal Resistance (R -Value)
Loose Fill TYP BLOWN IN
Brand CERTAINTEED
14.314 inches
Contractor's n 't installed weight square ft 0.615
ManufacWree nstalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR V `'LL ,
Frame Type
-
A. Cavity Ins dation . BATf
Brand Name CERTAINTEED
Material
3112
Thermal Resistance (R -Value; R-13
T'h� ickness fiches
B. E�n ro Fro F :gym Sheathing
Brand Name
—Matedal
Thickness inches
Thermal Resistance (R -Value'
4 FLOOR OVE GARAGE AREA i
Brand Name
Material
Thermal Resistance R -Value
Thickness it I1eS
5 SLAB FLOG 'PERIMETER
I
Brand Name
Material
Thermal Resistance R -Valu
Thickness it ,les
6 FOUNDATI( , WALL
Material
brand Name
Thid! c tineas ;hes) _
Thermal Resistance(R-Value),
Declaration
I hereby certify gat the above insulation was installed in the building and the above location in conformance with the current
Energy Effrcien , Standerds for residential buildings (Title 24; part 6, Califronia Cade of Regulations) ae Indicated on the
Certificate of G *ipiian , where applicable.
2,3A 4/25101
PARAGON INSU ATION _
Item #s nature, Da
Installing Subcon- actor(Co. Name) OR
General Contract (Co. Name) OR Owner
Item#� Signature, Date
installing Subcortmetor (Co. Name) OR
General Contract (Co. Name) OR Owner