0112-031 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under 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.
License # Lic. Class rr' ff Exp. Date
tt'S .O a C36 �� � v' �✓ rrl � � Mi 12.0
' r
Date✓G�� Signature of Contractor' `° r
OWNER -BUILDER DECLARATION
I 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 isnot 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).
( ). I am exempt under Section , B&P.C. for this reason
Date Signature of Owner,
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 3700 of the Labor Code, for th~e
performance of the work for which this permit is issued.
( ) 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:
Carrier FX. M -PT Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
(,F'f "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 Califo(nia,/and a�ree,that if I should become
subject to the workers' compensation'prf isionnpo ect'o 3700 of the Labor
.Code, I shall1forAfiw,ith comply with thosQ'1provislons�', '
Dat e:.✓: �i�.�/`k.of Applicant—,
j'�� z_,.:a3° sf 1A "144
Warning: Failure to secure Workers' Compensation Co. rage 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
any permit issued as a result of this,applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quita, its 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, or cessation of work for 180 days will subject permit•to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with ali)City, and State�aws relating to the building.,
construction, and hereby authorize representsl�tves of this City to enter upon
the above-mentioned property foFinepec jon Lrposes.
Signature (Owner/Agent) } ?�r Z-11 < ! d% Date LA ,
t;
BUILDING PERMITPERMIT# _
DATE VALUATION LOT -� TRACT
f1'Beb
JOB SITE
APN
ADDRESS 10_115M WA trAC. ACCO
d
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CARL 1K.).D1;�t :fj•X.*.G
CMf aFSt:A0a3iSG`°fA TH
48-509 VMENVAITMN -
7X347 MIX BOx
LA QU1MM
11W rr�3" kWus, CA 912-392
('760)244-6341 c,21,448-7,1
USE OF PERMIT
VALUATION LZ
ESIM"'�'�Z COST OF
P1;"1 WffFAW. WAKW3 RY
CONS RUC`:10N FEE 101-000.4 d &,000
PLIMAING IMM, 101-000-419-000
nFr, 0 6 2001
( MY FLAQURABT�
Y. i. Flly;���F
e���-�ra�°��.�;ty���.�:�c�:���Inqq�llz�t,•,�q�q�e����,,xy'��(�^��••��"�W�,•}}+;��
��jjoo[�nn.:���qqu6
• . i:rl3,�dn7 ,IC�L�dY"3'RTi.A/Ati7d:�'
r9iI.lMV
1'0TALPER1M_,FP2 S —DUE, NOW
822M
•;
c�
RECEIPT
DATE
BY
DATE FINALED
IN
PECTORIf
INSPECTION IkECORD
OPERATION I DATE 1 INSPECTOR
BUILDING APPROVALS:
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
nnnvall _ Int 1 nth
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air .
Combustion Air
Exhaust Fans
T.A.U.
Compressor
Vents
Grills
-Fans & Controls
Condensate Lines
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
-
Temp. Power Pole
Underground Conduit
f
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
-
Exterior Receptacles
G.FJ.
Smoke Detectors
Temp. Use of Power
a
Final
Utility Notice (Perm)