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0301-130 (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 777699 13 000/2C pate �� %� Signature of Contracto�� ,J� OWNER -BUILDER DECLARAT ON 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 Bile (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). ( ) I am exempt under Section , B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION 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. (,Vh 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:. Cartier I11ERTY; �RUTUAL Y' Policy No. W.A:262D 72"1.2T[ (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 forthwith comply with those provisions. Date: -4 Applicant Warning: Failure to secure Workers' Compensation coverage is unlawful 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 resujt%ofsthis applicaton agrees to, & shall, indemnify & hold harmless the' City of LiPbuinta, 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 representatives of this City to enter upon the above-mentioned property for inspection purposes.: Signature (Owner/Agent)' Date BUILDING PERMIT PERMIT# DATE VALUATION LOT � �'tftX TRACT r JOB S(T& j� APN ADDRESS �5 V.11 0. .... OWNER I CONTRACTOR/DESIGNER/ TOOLI..+;'`vRQ"MRS WC - TOT 1, BTZ0TMZ8 MC -_ _ __ _ . 73+121 1lM- WAR NG X100 73.121 1-M) WA.;RUNG0100 .PALM ]'VRRT 93260 1".°AUT. DF -S RIA CA, 92260 (76q)674-96", CWt 3832 USE OF PERMIT / NFD > LOT 65 aWX]w92`111 'A., PERMIT DOHS NOT YNCL.d..DDF AL,OCX �--- WALL,.% POCDW3PA OR. PRI !P'V+/AY.APPFI0ACK 751; PLAN CHECK x'1+:1;: ,p„E'1n U T 1024 OUB TO M'UVIPLE, ISSUANCE OF SAML PLM TYPl:,- CU1111TOM COMMUCTION Uftoo OF PORCIOPAPTO 275.00 SF C1.1' RA:WC.EaiFti ORT 610109 SF Eunwxl "-i COST OF CONISIRUCM00 FRE 19um"Ry COTS°!'RUCT10�4 FEE 101.0100.418.000 $1410313© PLAN COMM- K FEE 101-000-439-318 MECHANICAL FEE 101-000-421-000 11111,E iP>f„WrRJCAL 716%, 101-000-420-001 $166.20 PI.[DMB0113 ME 101.000-.419.000 SIPA,00 S•C2 P-00 NOTION M - RESID 101-000241-000 $23.37 GRA,i311<!iC1FRE 1011.000.423.000 SK00 DEV. 'iW&'3?-11.1[dtPAC,4` FF E $2,405.00 AAT IN PUBLIC PIA. C!"M - R.1AIC 270=000-445.000 $81.33 . _ _ I I JAN 2 2 2003 CITY OF TTA 10N AND PLAN 0 ptlaw TEEN "IYUR NOW RECEIPT I DATE` / 4 l I BY 11AP�`FIN/(L56i �(� /� INSPECTOR $4,324.90 $0,00 .YS; � INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade 50Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap —tGj ,aT>7 F.A.U. Framing gj Sg _ a Compressor Insulation , p Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath / Final — BLOCKWALL APPROVALS Finai POOLS~- SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I 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 Pool Cover Sewer Connection /�p 3_ � Encapsulation Gas Piping Gas Test — Appliances Final Final Utility Notice (Gas) J ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring j /J Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: v1 v �- -Cj'