0206-072 (BLDG) (3)hereby affirm, under penalty of perjury that -,I am.licensed under provisions of
*Chapter a (commencing with Section -4 Division 12 of the Business and
Pr6fessionals Code, and my Liiierisiitis in full force and effect:
License #
uc4ss Exp. Date
CY
LU
�z�
ate Signa61"Cbritractor0 1
4 -0A
% T, OWNER BUILDER DECLARATION
_J a f 11A
I hereby affirm under penalty 'of',064dry that I am exempt from the Coniractor's
License Law forlhi following reason.
1, as . owner of the property,! or my employees with wages as',their sole
Cornpensation;,will do,the work, and the structure is not Intended or offered for
SaIii (Sec. 7044B6sIhesS & Professionals Code).
1;, as owner, of.the-proorty; am exclusively contracting with licensed
3 *stru the 'pr6ject '(S&'.7044, Business,& Professionals
,c ra o Tto
ont. rs
.4
!kCo
xem Un er S
kr B&RC, for this reason
ection,
.06
natA ;4 ,
CL
WORKER'S COMPENSATION DECLARATION,
-jI,.hereby affirmunder.0enalty-6f,,pibrjury one 'of,lhe following declarations:
I.have and will maintaln.a certificate of'consent to self -insure for workers'
'.I - ' ,
X w,_LLA'q,, .,,compelisation,,�gilprovided-foriby1Secti6n,3700 of the Labor Code, forthe
0Q j performance'61! the work for %Wch this permit is Issued. 7
I have andQ11 "maintain workers as required by
0 S
n. 3700 of.the,Labor Code'for'the performance of the work for Mich this
a; , 16
Perm , ft. IsSued.!My� Workers'; opmpensabon, Insurance carrier & policy no. are:
�,arrlerC LROJON-Ift CO.',� Polky,No. WC31
;,.
�,(Thls section need not 68 completed. N the permit valuation Is for $100.00 or less).
.41 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'Ca.lifomia, and agree that if I should become
-'subject to the workers' compensation. provisions of Section 3700 of the Labor
Code,.Ihal�ff rthwith comply with thos
Date- Applicant z1ad—ma
V_
iwe;nIng: failure to secure Workiirs' Compensation coverage is unlawful and
'n shall
,shall s6blect an employer to criminal penalties and civil fines up to $100,000, in
addition to the.cosl of compensition, damages as provided for in Section 3706
f i of the Labor Code; Interest and aftomey';3 fees.' 4
51YIPORTANT, Application Is hereby made to the Director of Building and Safety
7%r• a "Permit subject to;: restrictions set forth on his
ti .
app pa on.,,.
V, I
111. Each person upon whose behalf this 'appli6ation -is made & each person at
v
-1, whose request and for whose benefit work is performed under or pursuant to
,any permit'Issiled as 'a result Of this applicaitoriagrees to, & shall, Indemnity
6 the-,Cky of
Quintai,lts offlcers,�agents and employees.
hold harmles
112. Any, permit iisued as 4'result '6f this application becomes null and Vold li.
80 days- from date of. issuance of such-
4!,workAs,not commenced.withinl
�. 11, , '6f
r,14i Oermit,'or cessation work for 180 days will subject perm to cancellation.
�"I 16e'itlty'ihat Chive read this application and state that the above ihf6nmafion Is,
Pcorrect. [agree to'comiply,with il(Cfty, and,Stete-laws relating to the building'
.46ristn]ictlon,. and. hereby authodze-re'Pr6sentatives of this Cify to enter upon
thb above-mentioned property for, Inspection pur .
poseS
nature (Oiw'nie"r/Agent) Date
4
41;, BUILDINGfERMIT..,
6206-M
I . . I " LOT
DATE 'VALUATION a TRACT S'
JOB SITE
ADDRESS 'IWO. 3 TANGLEW OD X5:&Z-
APN
OWNER
CONTRACTOR DESIGNER ENGINEER I
PGA W= RkMENUAL HOWOWNMI,
WO WMAM MM1n.FA1iO4Y CORP t'
P.01 BOX 1005080
M OMM FLAIR 0 105
A QTWA! CA 9225.3
�A
SAN DIEGO CAAr,21122
USE OF PERMIT
GENEMBUIUM410
SEISMIC MR0.F1T;_BL00. 3. 54.583, 34.5189, 54.505,
VALUATION L-3
ENTMATED C09f OF CONMUCIUM
POO= FEE HUMMMY
CONSTRUCTION FILE 101.006-4-18r000 $439-50
STRONO MOTION YU • MIL) 101 -000 -241 -Mi $6.00
4".
HuWroTit CONI' ,= MORARD PI -M MMIC
S463_50
L 93 PRF -PAID FM
WOO-
)OTAL PZRMJ,'MS DUE NOW
2, 1'2002
_�jJ7,
CITYOFLAQUI�TA]
FINANCE DEPT.
t,, RECEIPT
DATE�
iA
I
BY
tD L
Dffi7
I PECT,6Y
, .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
set Backs
Underground Duds
Form & Footivigs
Ducts -
Slab Grade - -
Return Air .
Steel
Comte Air
Roof Deck _-
Exhaust Fans
O.K to W
FA.U.
Framing
Compressor
insulation
-
Vents ,
Fireplace P.L.
Grills '
Fireplace T.O.
Fans & Controls
Pa Wai&loautation
Condensate Lines
Party Wag Firewall
Jf
Extenor Lath
0 0
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
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Pilling
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateial
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�W / /A "Z
f 9��` d Z ,�iw `f7 orL�oz-.
`%We 114,14fWiri/
�),•��/�� �� d2
�� '•��j i'v/q� �U�(/ ,583 6ZcS /d��
ANA( 6/? /�9/0
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rh
Low Voltage Wiring
Fixtures
Main Servire
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Defectors
Trip. Use of Power
Final
Utility Notice (Perm)
09/17/2002 01:04 7609227550 FARNSWORTH IORO
09/16/2002 13:06 7609227550 FARNSWOFTH TORO
Verbal DWUSSI*na 4krWor.InstrucOona m i h,Contraotor/Architect; .
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09/20/2002 14:53 7609227550 FARNSWORIH IORO
Verbal Discussions and/or Instructions with Contractor/Architect:
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09/22/2002 00:33 7609227550 FARNSWORTH IORO
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09/23/2002 23:52 7609227550 FARNSWORIH IORO
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