0309-079 (SFD)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty mperjury that i am nmenoou under provisions of
Chapter 9(commencing with Section 7000) ofDivision 3of the Business and
Professionals Code, and myLicense ioinfull force and effect.
License # ^ Lic. Class Exp. Date
Date 1,x4 1 Signature of Contractor
--_R----ER _---_—.--'
| hereby affirm under penalty of perjury that | am exempt from the Contra omr'o
License Law for the following reason:
( ) |, as owner of the property, or my employees with wages astheir sole
compensation, will do the work, and the structure is not intended o,offered for
oa|6(aev. 7044. suomeoo u Professionals Code).
( ) |, as mwnorof the property, am oxome|ve|y contracting with licensed
contractors to construct theproject (Geo. 7044. ouoin000 u Puxvooiono|o
Code).
( ) | am exempt under Section s&PC. for this reaoun__�______
Date Sighature'o, Owner
/ -
WORKER'S COMPENSATION DECLARATION
| hereby affirm~~ndo, penalty or perjury one of the following declarations:
()| have and wilt maintain pcertificate ofconsent mself-insure for workers'
componmation, as l5mvdod for by Section 3700 of the Labor Code. fo,'tho
performance u,the work for which this permit iaissued.
Q | have and mmointainwmnmrs'oomponmationmoumnmu.00mquimdby
Seb!tion 3700 of the Labor Code, for the performance of the work for which this
permit is issued myworkers' compensation inounan0000nio,& policy no. are:
Carrier / Policy No.
,tZATIOMAIUNlON K
(This section need not becompleted ifthe permit valuation iofor $1UO.00mleoo.
( ) | certify that inthe performance of the work for which this permit iuissued,
| oxan not employ any person in any manner so as to uonomo subject mthe
workers' compensation laws mCalifornia, and agree that x| should b
subject to the workers' compens t' n ovisions of!Section 3700 of the Labor
Code, 4 shall forthwith comply withMth spe�provlsions.
Warning: Failure msecure Workers' Compensation coverage ioun|avwu|onu
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to -the vo�tmoompanoonon.damages eonmm
vioou,inaomivnu7oo
o,the Labor Code, interest and attorney's fees.
IMPORTANT Application iohereby made tothe Director o/Building and Safety
for u permit subject to the onnmnono and restrictions set forth on his
application. .
1.Each person upon whose behalf this application |omade aeach person a,
whose request and for whose benefit work ixperformed under o,pvmuun(m
any permit issued as result o,this appnoomn agrees to, u ohan, indemnify
a hold harmless the City mu^Ouinto. its officers, agents and employees.
o. Any permit issued aoaresult ofthis application becomes null and void if
work is not commenced within 1e0 uora from umu of ioovanvo or such
ponnx, or cessation ofwork for 180 days will subject po,mit'tocancellation.
| certify that | have read this application and state that the�above information is
correct. I agree to comply with all City, and State I J�ws relatin6 to the building
construction, and hereby authorize representatives ',,of thi's City to enter upon
| oate--_�_–_--
. -
BUILDING PERMIT
DATE' YALUATION LOT' TRACT.
JOB SITE
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
TOR' 62
USE OF PERMIT
QARACWXW�.�ORT 31F
J�STIAIATXX CONT 01r
PLAN, CHEICK WE 101 -6�00439-318
'491 'M, 3bTAWDP
XTE, NOW
0 01
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
A
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 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final —47VPOOLS
BLOCKWALL APPROV S
- 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 APPROVALS
Gas Test
Electric Final
Waste Lines
p - / c 3 S.
Heater Final
'Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
' O'.K. for Finish Plaster
Sewer Lateral
" ' Pool Cover
Sewer Connection
-1 .03
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL"
Temp. Power Pole
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: