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9602-126 (SFD)LICENSED CONTRACTOR DECLARATION I hereby affirm 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.`CIO�s��9XXP -Date Date kI(7 /7 i0natureofContra6 \ 2,(!/ "._ •r` A111 f OWNER -BUILDER DECLARATION.t' w_ I hereby affirm 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). () I am exempfunder 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. () 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. Policy No. (This section need not be completed if the permit valuation is for $100.00 or less). () I certify"thatflhlb;Pperformance of the work for whiMM1't&rrkfl eWQis 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 toworkers' compensation provisions/of Section 3700 of the -Labor Code, I shafor4ith compl with ose,provisions Warnlrig: Fail "Ore to secure Workers' Compensation cove -rage 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 resylt of this application agrees to, & shall, indemnify & hold harmless the City of>India�n Vllellsijis/offiicers, 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 authorise representatives of this City to enter upon the above-mentioned property forinspeation' p rposes. r Al Signature (Owner/gent)" I !' /zf�.// { Date �i,1'I'All /.'1 ALC BUILDING PERMIT PERMITi DATE123a!�jti VALUATION S214d„ 33t i.4f3 LOT iU TRACT 2k31.4, ,x'HASE ) JOB SITE ADDRESS APN 55.5518 SOUTHER MLLV 7f?r-44644i OWNER CONTRACTOR - RANC.HO CAMSTR AN0 DEV1''t-0P,N9.Rtk KSI.. L AN'D 11 79087 COMTRY RY CLIJS DR #20 -14th ai'i BLVD, � B "s1�ii U i i l3G`NL•'S, . Cel 9220I 1,A f<'+LOi"rA CA 92253 fel OY'1rt15_ 1'7Sk r.111,4 1060 DESIGNER/ENGINEER B13G ARCHITECTS 26 COMRATC PARK USEOF PERMI Z"INGLR FC.ANT flLY DWELLING i%INk. ..CA 92714 1TW,-Hf;R1TAQE COMtai^CTION - PGA WEST P11M 3 -CR FEE DESCRIPTION FEES-- CUSTOA4 CON TRUCTION 4,441.00 SF :PORCl:i PATIO 519.00 SF - CIARAGOCARiPORT 583.00 S.F ESTIMAff,W CO:6'T O.F CONSTR.IJCTIOiN 296,U3.40 PERI ITY FEE $"tJ1 MARY IMAIN CHEM FEE I4.1-000-$39-3if( �1„(iSfi 92 CONSMUCT1ON PFS i©.1-000-41$-000 $1,294.00 i1 EC•-t"ICA;L • P,, 101.000-421-000 $124.00 1R,.GC!WCAL fEF, 101-000-420 Q00 $189.60 1 LOWN03 FEE.. 7EY1. 25 S 1'O"N a im arm 1 - mf.►113 1014M'211-000 $28.84 GRADING FEE 101-000-42-�=(D(i(i $20.00 1-fFTtA'%1".1t.LTL".TUREFFE '225-M-44.3-342 .$6,000.00 AltT .tN I" UB14C,, MAC '$ MRSM 701^11011-2554)00 5465.% SUI3-'I l7'1' 1L C•C,�Ivr� Cl2 UC'��URA �rTI� I'Lt�tif CHECK $0,392.37 LESS, .PRE-PAID.FTES $0.00 TOTAL g'ERJti'I -Y EES DUE NOW $9,39137 I . RECEIPT. DATE By DATE RNALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings T.o Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans OX to Wrap 10, F.A.U. Framing Compressor Insulation L 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 POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final Gas Piping PLUMBING A PR VALS Gas Test Electric Final Waste Lines 2 Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans OX for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICALL11%0P VALS Temp. Power Pole MAWR Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G. F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: