0108-144 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of'the Business and
04 W Professionals Code, and my License is in full force and effect.
C =) M License# Lic. Class Exp. Date
LU
L
~ Z r- f Date i 'Signature of Contractor.
CO0~ l
I.—C:0 _ M __ OWNER -BUILDER -DECLARATION
J -
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Ir—to License Law for the following reason:
Z_ ( ) 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).
L0O I am exempt under Section B&RC. for this reason
N
Date Signature of Owner.
O rn
a Q WORKER'S COMPENSATION DECLARATION
O� Q I' hereby affirm under penalty of perjury one of the 'following declarations:
r IQ— O (.) 1 have and. will maintain a certificate of consent to self -insure for workers'
X W �L- compensation, as provided for by'Section 3700 of the Labor Code, for the
m J Q performance of the work for which this permit is issued.
Q O O I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
(I:U-)H permit is issued., My workers' compensation insurance carder & policy no. are:
z Cartier Policy No.
ob �.
g (This section -need not be completed if the permit valuation is for $100.00 or: less).
O I certifythat in the performance of the work for which this permit, is issted;
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.
come
. _
subject tthe rkers' compensation provisions of Sectio 3700 61 thabor
Code;'d's " with comply with fitti �e provisions c`
Dater �° Applicant loft
Vllarnng: Failure to secure 1Norkers' Gompe sation 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 the conditions and .restrictions set forth on., his
application. r
1. Each person upon whose behalf INS application is made & each k§bn at`
whose request and for whose benefit work.is performed under or pursuant to
any permit issued as a resultof this applicaton agrees to, & shall, indemnify
CU & hold harmless the City of L . Qulnta its officers, agents and employees.
2 tAny permit Issued as;a resulNof this application becomes null and void if
won-, is not co'mmerced within'=180rdays from date of issuance of such
permit; -or cessation of'work for 180 days will subject permit to cancellation.
i certfyhat`l have"read:.this;application andstate 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 CiIt' er on
the above-mentioned. properry,for inspection pypos s.
Signature (Owner/Agent) M - ~--D`
BUILDING PERMIT PERMT#
DATE;, VALUATION LOT 4108-.144 TRACT
3/1.:1/'01 Sm
JOB SITE
APN
ADDRESS
'19-216 HAVEMA.
OWNER
CONTRACTOR / DESIGNER / EN INEER
Vr,RNA GR3_ X, G
1 014 I A4411"CH i`E15fidN
78-214 DAMNDA
7271/3 RAMIDNRD,
LA Qu;fNTA CA. 921'$3
'>.THO'USA D FAL;AIiS +; 3%, 92376
USE OF PERMIT
PLUMONG
WS6TAL.L, 50 t?? J.,. HOT "&'1ifii fi'.1`fFAii'LR (:I2EPLACKMENT)
VAIXATION
qq'� $yy1y�� ��7}a/y�y�yX��y'1324A'l�'lL►<Lt��'€?�'�':i7t�M11CM0,N
6����.D17KIR SL1.SS'.�.TYii'Af.I. S. �
1tl1iL►9Lf91•F�3 f< �' , 101=000-419.000 $23,30
WB-TMii•;101+I tUMOM.AYd'L'tVL,PXf.G"`L7%t^M
$22.50
LEW PRE -PAID M3
30.00
TOTAL PxRmn.'III= DUE NOW
RECEIPT
DATA
.� /f !,�
BY
DATE FINALED'
INSPECTOR
INSPECTIC�.GN RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILMNG APPROVALS
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
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
SL OCKWALL APPROVALS
POOLS e SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBNG APPROVALS
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 �y
Gas Piping
Gas Test
Encapsulation
Appliances
Final
Final
Utility Notice (Gas)
ELECTRVCAL A P RCVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F. 1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)