9907-626 (BLCK)LICENSED CONTRACTOR DECLARATION .
I hereby affirnunder penalty of perjury that I `am licensed under provislons'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. Class a Exp. Date
9
Date Signature of Contractor.
1
OWNER -BUILDER DECLARATION
(.hereby affirm under,penalty of perjury,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)..
as owner of the`. property, am .exclusively contracting with, licensed
contractors to 'construct the project (Sec. 7044, Business &- Professionals
Code):
O 'Iam,exempt under Section = ,; B&P.C.-for this reason
bate." Signature'of Owner
WORKER'S COMPENSATION DECLARATION •
I hereby affirm under penalty of_ perjury,one of the following, declarations:
() ,j 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.-
(>)z 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
per is issued. My workers' compensation insurance 'carrier,&'policy no: are:
Carrier f Policy No:
ATIR FU�M 2 MY -99-0 013 7151
(This section need not.be.completed if thepermit valuation is for $100.00 or less).
I certify that in the performance of the work for which this permit is issued,
I shalt 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 workers' -compensation provisions•ofection 3700 -of the Labor—
Code, I s all forthwith comply with,thdsg' ovisiorfs`.
Date-'-/-?! JAY 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.. 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
:zany permit issued as a result of this,applicaton agrees to,.& shall, indemnify
.& hold harmless the City of La Quintal its officers, agents and employees.
2. Any.permitissued as a result of this. application becomes null and void if
work is not commenced within'.180 days from tdate'of•'.iss_uance, of s6cFi
permit, or cessation of work'for. 160 days will subject permit to cancellation:
I certify that 1'have're'ad this application and state that the above information is
correct: l agree to comply.with all City,. and State laws relating to the building -
construction, and hereby authorize'representatives of this -City to enter upon
i the above-mentioned property for insp eti9;w urposes. -
/"
V Signature (Owner/Age j ✓��'"'1 --� Date �7
ht BUILDING PERMIT PERMIT#
DATE VALUATION LOT
TRACT •
-JOB SITE
APN
ADDRESS 47«380V CORDOVA..
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LRE GvUkS413
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f akl Uti'�TA C.A. 92253
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USE OF PERMIT
80 L,ii". x 5' Sa: ISIS. XV ►51'.kf( �� �S'Fts 9 a4 i'.i't .�l','�t4�r1ii6)�
6t'F:tR� .1'.�, iO `1;P1,h'Y• Wbi� �wtJ1r���at Y�.4'.iq 1 d!�..�'3'V
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I CJWS" RIL1v11H )N 11-07, - - 1014df1t1-41'-C1t)1.R $41.00
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RECEIPT
DATEBY,'
DATEFINALED
X11..
INSPECTOR
i
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam 8. (�j. Q
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING 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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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: