0103-052 (BLCK)LICENSED CONTRACTOR DECLARATION
l,hereby.affirm under penalty of �perjury that I am licensed under provisions of
Chapt" (commencing with'Section7000) of Division. 3 of the Business and
Pr6fesdonals Code, and my License is in full force and effect.
License # Lic..Class, Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm unde - r penalty.of perjury that I am exempt from the Contractor's
License Law for the following reason:
1, asowner of the property, or my employees with wages as their sole
dompensatfi;5h, will do the work, and the structure is not -intended or offered for
sale (Sec. 7044, Business &.Professionals Code).
1, as owner 'of the property, am exclusively contracting with licensed'
,..Contractors to -construct the-7roect (Sec. 7044, Business & Professionals�..
Date 3- �J. —Sighature of Owner
'WORKER'S COMPENSATION DECLARATION
I hereby affirm under- penalty of perj ury 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 the
performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
4.Asqtion 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:
Carder Policy No.
,(This'ig(Abn need not be* completed if the permit valuation is for $100.00 or less),
)�O)'l 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 California, and agree that if I should become
subject to the wdrW6irs' compen�ation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with th rovi
Warning: �ailure to secure Workers' Compensation coverage . is unlawful and
shall subject an employer to criminal penalties and civil f ines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and fees.
IMPORTANT Application ishereby made mthe oimnto,u/Building and Safety
for o permit subject to the conditions and mvhmiuno mm, forth on his
application.
1. Each person upon whose behalf this application is made &each person at �
whose request and for whose benefit work ioperformed under orpursuant m
any permit issued aoaresult o/this opp|inatnnagrees to, & shall, indemnify
& hold harm|°oo,txeCity of LaOuinto. imnffioom, agents and employees.
. o.Any permit issued as result ofthis application becomes null and void if
~v,x is not commenced within 180 days from uouo of ioovonve of such
permit, o,cessation ofwork for 18Odays will subject permit to cancellation.
jcertify that | have read this applicationand state that the above information io
correct. I agree to.comply with all City, -and State laws relating to the building
construction, d hereby authorize representatives of this City to enter upon
the above-mentioned property for i eiXion,purposes.
Signature (Own `
BUILDING PERMIT
DATE VALUATION LOT TRACT
JOB SITE
APN le
ADDRESS
DAN FOWLER k
LA QTANTA CA 92253
IP,. ok 99.2s. -v
USE OF PERMIT
16 I.F. IY HIGH HL10c"K, WALL
CITYSTANDARD
5 Ff. WALL M00 IS
FRE SUMMMY
101-000-418-000
AAR 052001
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
Footings
Bond Beam
( 2 C �k
?� 0�R0j'
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final ��S _
PLUMBING APPROVALS
Underground Plbg. Test
Gas Piping
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: