0007-263 (RPL)CONTRACTOR DECLARATION
I hereby aff irm ty of perjury that I am licensed under provisions of
Chapter 9 (commekncingg wi In' Section 7000) of Division 3 of the Business and
Profe,-Jonals Code, and my License is in full force and effect.
656128 �a» � ,v,�^^��
�v~
Date sig�mvmm Contractor
OVVNER'BW|mmERoeCLunmnON
| hereby affirm under penalty ofperjury that | amexempt from the Contractor's
License Law for the following reason:
( > |�.00owner ofthe property, or my employees wimwagesaotheir sole
will do the work, and the structure ionmimon ded moffered for
vo|e(seo.ro44.Business 8Professionals Couo).
( ) |, as owner o/ the property, am exclusively contracting with licensed
oontmomm to 'construct the project (Goo. 7044. Business & Professionals
Code).
(>|umexempt under Section �.omPC.for this reason
_____�___
Date SignaturemOwner
`
^
WORKER'S COMPENSATION DECLARATIONI hereby affirm under penalty of perjury one of the following 0ecla,rations:
�
I have and will maintain a certificate of cons6nt4o self-insu I re 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.
I have and will maintain workers' compensation insurance, a . s required by
SGion 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrierA policy no. are:
Carrier �,,TATE 1nj1q1) Policy No.
.
(This section need not be completed if the permit valuation isfor $1ou00 or less).
() | certify that inthe performance oxthe work for which this permit ioissued,
| a»on not employ any person in any manner so as to become subject mthe
workers' compensation laws cxCalifornia, and agree that x| should become
subject mthe workers' compensation provisions of SooUyn 3700 of the Labor
'Code, | shall forthwith comply with those proxaio S.Date: 'Q
—
Warning: Failure to secure Workers' Compensation coveria`ge 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 Directo . r of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
1. Each person upon w . hose behalf this application is made & each perkn at,
whose request and for whose benefit work is performed under or pursuant to"
any permit iuouoduoaresult o/this appicamnagrees to, & shall, indemnify
8 hold harmless the City.of LaQuimo. no u#ioam, agents and employees.
o. Any permit i'ouod as amouKormia application Ueuvmoo nun and void if
work is not commenced within 180 days from data o, issuance of such
permit, o,cessation ofwork for 1OOdays will subject permit to cancellation.
| certify that | have read this application and state that the above information is.
onnoo. | agree mcomply with all Qty, and State laws relating to the building
oonot,umion, and hereby authorize representatives ofthis Qt� toenter upon
the above-mentioned property for inspection purposes.
'
Signature (Owner/A:gent)
~r '
BUILDING PERMIT
bATEi�1,1�16� NALUATION LOT TRACT
JOB SITE
ADDRESS 4&S34 F"AMMINO
APN
OWNER
CONTRACTOR DESIGNER EN61NEER
PO BOX 1716
-744 2 5 J0141 DRNF, #A
A Qum. DA CIA. 92253
PALMDESEM CA, 92260
USE OF PERMIT
-P001, MD10-11 SPA
POOL SPA ONLY-ALARMSMAMPRS SHALL 89 IN PLACEA.TPRE
M MIS PERMIT. WAVF-,R MATURE BBQ. A14SI 2.21-381993
VALUAT)ON 147".00 La
PLAN CHEM FU 101-000-439-318' $117.00
CONSTRUCTION F99
MECHANICAL FZIE POOL 19.,1-000-421-000
AUQ 1.8 2000
LL -3Z PRE�PA123 FEfit7
$0.00
'TMAJIFEMMITIM-NDUR HOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
77�1
INSPECTION RECORD
-- OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
i5teel
Underground Ducts
Ducts
Slab Grade
Return Air
Combustion Air
loot Deck
Exhaust Fans
).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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond —�
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
_
Underground Plbg. Test �G!00..,-
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
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)