0301-074 (SFD)LICENSEWCONTRACTOR DECLARATION
I hereby afiirm" under penailiy'of pe I riury th,at I am licensed under provisions of
Chapter 9 (commencing with Section 7000j of Division 3 of'fh; Business and
Professionals Code, on�myuovnoo�mxmmmeand anoo�
�"
unon� �m ua�
33 141C ' !�~~-
/Date Signature of CoAlractor
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that am exempt from the
License Law for the following reason:
( 1 /, oaowner mthe pmpouv v,myvmvmvvevwith wages as their
compensation, will dothe work, and the structure isnot intended or offered for
sale (Sec. 7044� Business & Yrofessionals Code).
contractors to bonstruct the project (Sec. 7044,* Business & Professionals
I am exempt under S'ection B&Pt /for this reason
~~~ Owner.
' vU '
�
WORKER'S COMPENSATION DECLARATION
.
I hereby affirm under p6nailty of perjury one ofthe following- declarations:
yf a certificate of con'sent to self -insure for -workers'
compensation, as p vae or by Section 3700/of the Labor 'Code, for.the
performance of the work for which this permit is issued.,
I have and will maintain �vorkers- compensation insurance, as required by
S6ction 3100 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 3,'J*ATR FUND Policy No. 646-tju-no-'s
(This section need not be completed if the permit valuation is for �1.00.00 or less).
I certify that in the performance of the work for which this permit is issued,
workers' compensation laws of California, and agree that., if I should become
,subject to the workers' compensation provisions of Section' 3760' of. the Labor
Code, I shill forthwith comply with th6�_e_;"p`rpvisions.
Date
~~�~- '
Warning: Failure msecure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines upm$1OO.00O.m
addition uothe cost mcompensation, damages ooprovided for inSection o7o0
u/the Labor Code, interest and attorney's fees.
IMPORTANT An ion�xo,euymuoommooimm
o,o,am|dingand Sa��
for permit au�ect to`thn conditions and restrictions set, forth on his
application. / `
1'Each person upon whose behalf this application -is made meach pnmoheu
whose request. andfor whose benefit work ioperformed under orp
any permit ioou'bdonaresult ofthis opp|inatonagrees to, ashall, muomm|fy
m hold xa,m|oua the City o,Lu Quintu, its omvors, ag6nm and employees.
2.Any permit issued oaaresult of this application becomes null and void if
wn,x is not commenced within 180 days from date o/ issuance of such
ponnit, or cessation cfwork for 18Odays will subjectponni�m cancellation.
|ne�m�n,men,uu�mouppn�mvnando��the ' informationiscorrect. I agree to comply with alf City, and State laws relating to the buildingconstruction, and' hereby authorize representatives of this City to enter ulionthe above-mentioned property' 0 r inspection purposes.
PERMIT
-BUILDING
DATE VALUATION LOT TRACT
19
JOB SITE
ADDRESS VU, CONIQUIRrADOR
APN
OWNER
CONTRACTOR DESIGNER EN61NEER
79-2,95 r,44101110 4A Q)ONTADR
USE OF PERMIT
SIM - LOT 1P, fiLAW W.1 PERMIT DCAS NOT -INCIAMP, BLOCK
or
CONSTRUCTION FZZ ollr-'�60-418`000 31,29100
OVEWPUR IMPACT FES
ART YK PUD.
RM -TOTAL CORMUCLION AND PLAN MD.,
RECEIPT
DATE
1.13Y-
DATE FINALED .
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
Combustion Air
Roof Deck
6L 7_
Exhaust Fans
O.K. to Wrap
; _
F.A.U.
Framing
_ d _ _-3
Compressor
Insulation
6-7--3
Vents
Fireplace P.L.
If
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
— ,z
Final �.� --
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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 G`'
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— —3
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final �
Utility Notice (Gas) L
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:
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