9602-121 (SFD)LICENSED'CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (commencing with
Section 7000) of Division 3 of the Business and Professioriajs Code and my
License. is in.full force and effect. ' .5979Ip
License # Llc. Class 1 ,Exp Date / ,r
/Date ?V r.7f Signatureof Contract r• rir//. /K� /1�'
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.-
(
eason:( ) 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 of offered for
sale (Sec: 7044, Business & Professionals Code).
() I; as owner, of theproperty; am'exclusively 'contracting with licensed
contractors to construct the project (Sec. 7044; Busihess & Professionals Code).
() .I am exempt under Section B&P.C. for this reason .
Date ^ :. SigoatureofOwner
AWORKER'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'
comper`sation,,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 sectigNnQedlnot tie completed if the permit valuation;,is.fo5($j1LQP)Q0 or less).
() I certiN1hat 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 w�°• rkers"compensation Novi ons oSection 3700 of the Labor
Code, I sE�allf fthwith comply -with those seftprovisions. ,�
fate: t�APPI'cant ��,71 .7A i'/ir/
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,fo 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.permlt issued as a result/oQA-f4pis:gpplicatiop agrees to, & shall, indemnify
& hold harmless the City of Ih11 dI s, i 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 purposee&
/• M
Signature (Owner/Ag ) -Date
ALC M=17!
MIT16(12,•12.1
...�B�U_ILDING PERMIT ,l'F)F►A R.T ti
DATE "' i .' . "
VALUATION w.,.A .e,w ♦n.-
LOT s... TRACT
JOB SITE ADDRESS 5��6-;50VIN.K : ILLS
APN 76fo, w"S
OWNER
CONTRACTOR ,
Arr;ic� cis rtN� nev.,�:1?�vi�
11CP�VD a
"91.37. COUNTRY CLi. B DR 1,120 .
56.440 PGA iNAM.
$RltMill.J.ti :I3iJ:NES CA 12201 '
:LAOU.INTA CA 92253
; (619)345-:1755 Clef.,# 1969
4-10"
DESIGNER/ENGINEER
AST_ i A 17 IMTE .
26 CORORAT1, PARK
USE OF PERMIti.i (s M {^AfV1 , Y UW.E N(i .
IRVIW, 0 A 912714
'I HF KIM' A08 COL1XG F tON - POA WF,.Tr
:PSL AN'.:t-Alt
• - ,
FEE DESCRIPTION
FEES
Ci:J$'1'Oidi. G'O-NST1 ar.1014 7,65-5.00 3F
06ROWATIO 302.00 SI!
C3t11UlGOC AR 01tr 713.00 SIT
TIMI o d' M COST �i F CO STRUCTION
224,815.00
-PTAN C11ECK:ER9 $877.29
C'ONWE UCTIOYa•FIEF, 101000418.000 KOT7.90'
EUEE -tICAL 1-,k1+. 101 {)W420_000 $164.69
!?1�i.JLiR1`A[tJtr1;',P� ).(tt:-�f3(j�rii9-ffUO $lflg.2�'
.
7'f3fdG 9ar1,0N - t2i 8W 1014()0-241-000 122,48
82fL i
r
fNFRA,%'rR C i'ifld!~ rE6 225-0,00f�143-342 $4;957.913
rlR ►N i`I.I !„.i�s r'L!lCw� ., i? (rt' 7�!-i)i0-?45- 1?.
-
SU11,TO`t'.AL CONS7R1:.1crm AND PLAN G1:j: ck
$7;105.73
L.FS8 PREPAID Vt,HS
50.00
'
TOTAL PE9tAIIIT i1 JFRS DUE NOW
$7,7,73
-! • •ter ...
r
_i.
RECEIPT
DATE
BY
DATE RNALED•
INSPECTOR
-i i mot:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPR VALS
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 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
Final'
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPRqVALS
Gas Test
Electric Final
Waste Lines ry
Heater Final
Water Piping L
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral Me2
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)JV ( /0