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I her ffirm under penalty of perjury that I am licensed under provisions of
Chap (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
/33 152 13 1111C :1131103
Date 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:
( ) 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). ,•/ /r• '
(..) I am exempt under Section B&P.C. fbr this reason�v--�
'Date i. i- ---•, Signature of Owher ~ ;'"= t
WORKER'S COMPENSATION DELL/ RATION
I hereby affirm under 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:
Carrier aTATI FOND Policy No. f14601UNIT11E094IS
(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 previsions oL'Sectiori 00 of the Labor
Code, I shall forthwith comply with thoscr provisiOrs.
"Date: / " Applicant -- �• a <1 . _:
Warning: Failure to secure Workers' Compensation coverage is unlav f�ul and
shall subject an 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 performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quanta, 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 have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representaj+ves of this City to enter upon
the above, -mentioned property for inspectiorr drposes.
Signature (Owner/Agent):. "�' '` _ Datei .4_�. '1
4
BUILDING PERMIT PERMIT�#�4'���
DATE / VALUATION�4ta�
LOT TRACT
JOB SITE
ADDRESS 13. AW, 18 f:HANWIGNS -].?It 1
55' & 70
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
PGA Wffr k1' MDj'«.A3'. LAL X420C., 114
CEL MA P A( -°T IC GEN MAI 0,0NIIkAACr()'1
P, 01 BCJX.1 00
253 3 SOU 11 COAM FIIC�HWAY,'i:'1•:, 250
F:.A.C11J1W'fA t' A 92:233
CARDIFF By` HE.MeA. (`A 92(9)7
���i0)�i;�5-lUllD CLtZ,?i 5821
USE OF PERMIT
O1rY&M BUF.UMN1
BLA 19: 55-6A 33} fi5 658, i.4,cm. VC'►I, 7'ARY
rl 1%,(101i'lsa3AIL MCI 31AVOWS
V.ALf,t�, f1:7t 24,S1CG,OE1 1•'s
-EMMATED C -106r alt. c WIRI �AJO!j
141W.00
Pfix kIRMKx
C0)43T11,.U:'fJ0NIFPE 101.000-416.000 $t33.Off
STRONG MOTION P%X "SID 101 p00C1-241 _(k)t) $1.40
• D a p
FEB 4.3 1UO3
C1Ty OF
FINANCE U UIN"A
EPr
SUD-TOTAL. 0014 TRUC."'1"I.ON AND PI A9 cmuc ;
l 52,20
IX -05 fla-F'A.b FPM
sil,00
'VOTAL ]El':I~'UMf;t i�` IS DAIP. NOW
RECEIPT
DATE' "
BY_ !
E FI LED
INSPE R
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
0. K. to Wrap
F.A.U.
Framing
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 _ ,
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
al
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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
COMMfEN S:
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. _
oke Detectors
emp.Use of Power '
Final
Utility Notice (Perm)