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9602-080 (SFD)LICENSED:CONTRACTOR DECLARATION' It I hereby affirm that I am licensed-undei 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. iSr7i dd'� '" j!"iiiro License #� Lic. Clas$ . _r Ex4ate _ f Date / /r/h SignatureofContractor .I. vl jr77; 1, /1//1 lv'/ OWNER -BUILDER DECLARATION ' - I hereby affirm that I am exempt from the Contractor's License Law for the following reason: is ( ) 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).` O I, as owner of the property, am exclusively. contracting with licensed contractors to construct the'pr`oject,(Sec. 7044, Business & Professionals Code). O I am exempt•under Section f B&P:C.•for this reason ' Data t 6ignaturwafOwnar 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 37001of the Labor Code, for the performance of the work for which this permit is issued. r` () 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: Garner;Policy No. (thissection/he6&l%otrb"e.completed if the 0irMit Val uati6b.,H4oU0,00to0 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 subjectis, a workers' compensation provisions -,of Section 3700,o'f the Labor .Code, I forthr'Jwith comply wM th seQ,provlsions.Date: /t�.'/ ,h 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 tha 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 pursuanto any=permit issued as a result.of this application agrees to, & shall, indemnify , �. !,v is ,r.•1�. & hold harmless the City of n lil;i a lis, li 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, of cessation of work for 180 days will,subject permit to cancellation . - I certify that Al 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. Owner/ V Date Signature 4/41' � ( �) IX J "`C' _BUILDING. PERMIT PERMIT . DATE VALUATION 04V4,101015, rus LOT • . / 4i TRACT K 01� JOB SITE ADDRESS ' - P A.M. �EISa-4. 0 'M OWNER CONTRACTOR ter: ... ....`,(r ,.'p j.. ,Ry.��•1.N(,,iry`.Ct?[ f;,t'��+1'f;�Sf�J(".�[..�RN��}•.�DE-V7/'afrCln',It!il'„ aa , m } �f �.}:.'yy� q Atk,.�. Y'1.n L il..! �w r`�.f �.1�4 S.``.!"�r.l V �Jlw �'�,li,�.. i1A" 4•ia ! ,�' l';r!t. % 1,,,:f„±lJH 1 .i 1 CUU13 dJl,'l,f 4i) . 3 t�iJiv tilt' Lri�r3 i3iZ f�23 13.i i2ir111j: �r IIliivG;♦ A 322-01. ;HEP.MiJDAD1 UE. CA 92201. C.irt,L.# ;:t9ci9 .DESIGNERIENGINEER ; • ry��b It�!'I'�1I1eAT1�1+fAL _ • 1799.2 ,1v11TCITILL' SO, ITI USE OF PERMIT+.ti4kk i. ,, 3 .t',AIV 1 f U h .l-. _ Q - y 411V NP.("A ('714 - O'7ei 111.113E RYDEM C01ILF t tolq' AY k'C+A. WES'.f PHAS13 t FEE DESCRIPTION FEES, =T10M. CC)NS`t' 'iU("t'tON . 25450,00 SE' I'O4d,L'"HMATIO 2/15.00 SF - ARkCtF/C:Affl-' i'I�'1 ,527.00 Sig � y i P t1.R' T I: FE' S9I 'll�dAR pi til 1^11 i.l ltd d' Itfl-i 4(-4 P23,27 P23:t9 C 2dSt2ZUt"t`t3N E•' i01-t)gJO-�;.l t3i1 $1.007.00 IViE('•`k1JW(d;AL FE'8 166-dIC)()-421-000 FUsCBRICAL FIEF. 101-OOD-42,0-000 503479 Y7 t1MBIN0 FEE, ilii-WowX41(9-09)0 $167,25 7+3 0 MOTION FE13-1tEND 1,01-000-•2411-00 $X44 cfaAWNG F 101-000-423-060 F INFtZF°�..'S'iAUC TUBE FFIS 225 -4)4)0 -4d3 -3!x,2 ART IN PUBLIC PLACES UtSM 7111410-2-55-M si .-"14JTAL, c©rt ofttUc'"ti IO J A'l�D iC?�Fctt"�4nn 7>i�Q7.�if. o . t���YIi �GYii,� T+Y+n.0 .' ltd FEES9itli✓ N414'V$7,07 fl_ FEB 2 l ;1996'ZVI RECEIPT.',_ DATE BY DATE RNALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel .17 Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing e,7 Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Ot Exterior Lath Drywall - Int. Lath 6 Final Final BLOCKWALL P ROVALS POOLS - SPAS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING A PROVALS 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 Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APP OVALS 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) COMMENTS: