0009-064 (RPL)~LICENSED CONTRACTOR DECLARATION
I hereby,affirm under penalty of perjury that I am licensed under provisions of
Cha,�,t&g,.9,� (coi;mencing. with Section 7000) of Division 3 of the Business and
Professio ode, and*my License is in full force. and effect.
Licem6`# Lic. Class Exp. Date
Da
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury,that |anexempt from the
License Law for the following reason:
( ) |, as owner of thepmparty, o, my employees with wages as their sole
compensation, will dothe work, and the structure !anot intended o,onamd,hv
sale (Seo.7o44.Business & Professionals CoUe).
( ) | asof mo property, um exclusively contracting with licensed
oomraomm to construct -the project (8ao� 7u4*. auv000 aProfessionalsCodo). ' m '
( ) | am exempt under Section s&pC. for this reason
oom Signature of Owner
` VVOEma/TlONDECLARATlON
.|'xomby affirm under penalty of perjury one of the following declarations:
} | have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Cocle,jor the
:7 perf6rman�elf the work fo'r which this permit is issued.
maintain workers' compensation insurance, as required by
_11 have and will
Seki2nV700 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 UATE F U -ND Policy No. 229-09-0019334
(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' compensationedvisidris of Section 3700 of the Labor
,Code, I slail firthwith comply with those provisions.
Date: -
4.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall - Subject an employer to criminal penalties ih d civil fines up to $100,000, in
addition mthe cost n/compensation, damages auprovided for mSection 37OO
o/the Labo,Codo./mo,o�and aoome�ofees.
--- -r� --' '
MPo ��ma�n�m,�ymo�mmommvmmouiming��a�o�
for a povni/ ov��om mo conditions and restrictions om* forth 'on mo
application.
1..Each person upon whose behalf this application is made &each person at
whose requestand for whose benefit work ioperformed under o,pursuant m
-any permit issued ooaresult ofthis appnoatonagrees to, uoxoU.indemnify
& hold harmless the City o*LoOuim^. its officers, agents and employees.
2. Any permit issued as result of this application becomes null and void if
work is not oommonoed�i«�m
n �eo ueyu ,m date of issuance o/ such
po,mit, or cessation ufmm,xfor 180 days will subject permit to cancellation.
|uortify that | have read this application and state that the above information io
correct. | agree to comply with all Qty. and State |uwo relating to the building
and h bauthorize i of this City to enter
the above-mentioned property for ins016i`lonh1,, u P,,,Ses.---'
Signature (Owner/Agent)umv—
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE APN
ADDRESS 00 A
OWNER- CONTRACTOR I DESIGNER If EN: �NEER
COPIONA CA 91720 LUCERNE VALLEY CA 92356
(909)248-6045 CBLft 4335
USE OF PERMIT
Pom6sUPA SHALL rip, rWPlACE AT PRE
PLASTD MOPECT 1014.P001, LWIPMVTENCLOSUU 19 NOT INCLUDED
IN THIS PIMMIT
P0016 ANDOP, SPA 1500100 1 1.8
F1*WMXnj) COST OF CONSIXIMMON
PIM CHECK FRE 101-000-439-319 $105,30
C0NSTRUCTION FSK 101-000-416-000 $162.00
3I.ECTRICAL FEE — POOL 101-000-420-000 $45.00
PLUMBDIO FF'R POOL 101-000-419-000 S".00
90B f0*1 AT, CM NERUCTI-ON AND PLM MMIC. 1363,30
^,'I
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment
Under andFJ is
Un rground Plbg. Test
Final
G s Piping
PLUMBING APPROVALS
las Test
lectric Final
Waste Lines
Aater Final
Water Piping
Plu ing Final
Plumbing Top Out
Equipme ^
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
pa
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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
Final
Utility Notice (Perm)
COMMENTS: