0201-062 (BLDG)j,4 hereby affirm. under penalty of. perjury -that, I am. licensed under- provisions of iw
.,,Chapter 9 (coMmencin4'with`S'ectio6-,^-7006)'of Division 3 of the Business and
04 W -.,Professionals Code, and my License ii in full force and effect.
Tp
LIC." Class
-Ucense #
Exp., Date
CY
3 ILI
oZ �Date"
Sign atu re 6 f Contractor
OWNER BUILDER DECLARATION
1 hereby affirm uhd6r penalty of -perjury that I am exempt from the Contractor's`
` L -following reason:
cl) lcense'Law*ioiihe,
Z 6
.'7- I; as owner of the' property, or my employees with wages as th6ir sole
compensation,will i do the work, and the structure is not intended or offered for
,.
ale (Sec: - 70441 Business & Professionals Code).
:as , owner ,of: the propeirty,"am exclusively contracting -with licensed
"contractors o construct _the , project '(Sec.. 7044:,, Business .& Professionals
J:
1,16tiakempt- under. Section.
B&P.C., for this reason
D-ate`-ture
Signa Qwli er
a)
WORKER'S CO IVIPENSATION'DECLARATION
0, l,,.heVeby,,'Afflrm,.,un er.penalty':of perjury one
ofthe following' declarations:
haveand Will.malntaln icertific'ate of consent to selt-insure for workers'
. 14
till. ,.aq,provided'
X%" W C�Cornpdnsation,`for by. Section 3700, of the Labor, Code, for the
0
er7frrnanceof the work* for which thisp 'armit is issued.
-0-have ,an
d;W111 maintain workers' compensation insurance, as'required by.
ptVQ 3-1,1,'S6a6fi.13700 of the, Labor Cqdii;,for'the:perlbrmance of the work for whic* h this
"d.,My work� rs,�.
-F., ermit:,is: issue compeniation r insurance carrier & policy no. are:
Policy No
Z'
J.b V11111j"
04691UNF1
JVR6is`tWcp'n�ih!eed;hot bi§,.cbm0let6d'H:the 'DerrnitvaIU6tion is for $100.00' or less).'
�(J,0;certify tl�ai.in,the pe4�6 anceof the Work for which this permit is issued,
i
Lshall not em -ploy, any', person In any.manner'so as,to become Subject to the . .
workers;
c6mpeh6itl6n, laws of Califomia,�and ajr6e that if I'should become.
subject to th6,Workeii'.cbrnpdfiiation pro4islons ofISection 3700 of the Labor
rning: Failure to secure Workers' C6rnp*e,nSa-tion coverag4.is unlawful and
subjectlil an,je,mployer�;o cAiinal penalti4s'aind civil fines up to $100,000, in
litidt�to'thia66it,'6f-co-'i-hpg'n,satio'n; damages, as provided for in- Section 3706
he Lab6r'_6de-,1nter'est and,atfomey'6 ieis.
RTANTi,Appli6itloh,ishet6bi,.riiade to the Dii
irector of Building and Safety
�i - ti
(alr pbrmlt, ,s6bject,.to;! the'. conditions' and restrictions set: forth `on his
Ic tio
14
Each on, upon whose behalf this'application is made & each persoft at
;rIa u9st'ind for whose benefit work, is performed under or pursuant to
ny permit iss6e& as, a'resblt of.
this. appl icaton agrees to, & shall, indemnity
L��,hDl "fiar les's . the . City' of:LaQuihtaIits 'officers, agents and employees.
Any permit issued:>as a result of,this application becomes null and void if
i&rk- ii., - not 'commenced •Within 180 days from -!.'date of issuance of such
ermit, or cesi on'of work for 180 days will subject permit to cancellation.
kil" that PI t the above information is
y at I have ap ication and state'tha
rect..-'agree to comply, with all: City, aind'State. laws. relating to the building
istru6tion,.;and'.'kireby,aUth6nie"repres6ntativ'e't Of this ity to enter upon
Above-mentioried property for inspection pprposes.
nature (Owner/Agent)
ate
r)
z�Iat
A
PERMIT #
ria UILDIN•. G�PERMIT
L N
iku`ATi6A'.,� LOT TIV
A
ADDRESS
JAPN
PEBMA IDEA O Ulf,
OWNER
CONTRACTOR/DESIGNER/EN INEER
YIGAWriSTRFTjDIMIAI.ASSOCIA770kT
091, MAR PAC tFIC dENEMAL COMRACMIR
po-BOX. *1060
253 3 SOV111 COXTr 1UGTAWAY'.T13?,2,50
C4.A 92253
i;rm'SRA CA 92007
(769>564,95W (TBIAH 5823
USE OF PERMIT
W*7,CRU�ANTE0US
411 �41_
STRUCTURAL MOI)INCAT)ONS
4'
VA1:UM10114 I's
jAN
PI An RZTA
QU
R.'MMATEP Q017T OF CoN LS-,JATc-noK
2(1MIUM
REIRMTf 1sTSUMNARY
MISTRUCT10141TR '101.000.41131A)00 MOM
STROWn MOTION MY - RESID '101-(00.241-,0Q0
V09.00
LX-!� PRE-PAU? IWKS
$R00
TOTAL PF"If F EX S DAWT HOW
RECEIPT
DATE,
BY
DATE,&N SPECTOR
bi
Y
_ r INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fortes & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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 LIVE
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
Fewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances I
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 cf Power
Final
Utility Notice (Perm)
COMMENTS: ,/� Alkll
9-
l/ �ifi��lfi! x'11511
�Q �
Page L of
DAVE STEAVENS
Inspection Services
PROJECT:i (,A ko,c- INT - LC -C. C'o QS
ADDRESS PO --510, \-C2
te-ae'u, rbc i3;`.. PLA -d
BLDG. PERMIT #
ENGINEER:'�'4,s-,:�,,.3
INSPECTION TYPE
'PROJECT #
CC I E N T L.,-) E -'S
DATE r -N-;( 'Ic:0 Z -
ARCHITECT .�LA A -ti.,2 C.4
CONTRACTOR It t OlAk, PAC(r-Ic-
INSPECTION REPORT
L k 0 A
A—C!
ME
CERTIFICATION, OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially compli.69: ithipprove'd'plans, specifications and applicable sections of the building codes. This report covers
the 1ocation81tf'-th9w insb'ected only and does not constitute engineering opinion or project control.
CERT. NO. L98 INSPECTOR NAME 87 tJS
(Print Clearly)
DATE INSPECTOR SIGNATURE--*'-�-