0011-014 (DSF)' LICENSED CONTRACTOR DECLARATION
' + hereby affirm under penalty ofperjury that | am. licensed under pmvioion».n/
_Chapter 9 (commencing with Section 7000of Division 3'�the Businessand
` pm�aoimn�qCode, and myLmonan!oinmnmme.onuo«ay.
. uommo# . u�o�m ���o"m ~
'476108
Signature of C L:A
DER
--'—._---�-_---` ^
I hereby affirm under penalty ofperjury that |amexempt from the Contractor's
License Law for the following reason:
( ) |, avowner mthe pmporty, 6,myemployees with wages aatheir sole
compensation, will dothe work, and the structure isnot intended moffered for
sale (Sec. 7044, Business & Professionals Code).,
1, as owner of the property, am exclusively contracting with licensed
contractors to,construct the project (Sec. 7044, Business &.Professionals
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 of1he following declarations:
// have and will maintain ucertificate y.consent oself-insure for w"="'
compensation,, 3700 o/,�eLaborCode,for the
'performance of the work for which this permit missued.
'
I have and will maintain workers' compehsation - insurance, as required by
Section. 3700 of the Labor Code, for the performance, of the work for which this
permit is iss�tJed. *My. workers' compensation' in"surance carrier & 'policy r1q. are:
Carrier* Policy No.
STATE CUMPIRM) 41180
(This section need not be completed if the permit valuation is for $1d0.00 or less).
( ) 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' compensatiori laws of California, and agree that if I should become
subject mthe workers'
Code, I shall forthwith comply witl� those provisionSA
Warning: Failure to secure j2kers"t"mpensation coverage, is unlawful -and
shall subject an employer to criminal penalties and civil fin�es up to $100, , 000, in
addition to the cost of compensation, damages as provided for in Section 3706
ofthe Labor Code, interest and o«umey�meo� '
. .
MOnT4mTplicationis hereby made mthe Director mBuilding and Safety
for o ponniruu�m� m mn conditions mmnmiono set forth on ma
application.' . I ` '
1.Each person upon Whose behalf this application iomade & each pomon'au
'
whose request and for whose benefit work ivperformed under o,pursuant m
any permit issued ona result o/this appovamnagrees to, mohuo. indemnity
m hold harmless the City of LaOuinto. its officers, agents and employees.
3. Any pomnit"ionuodauaresult ofthis application becomes null and void if
work is not vnmmonvou within 180 uoyo onm dam of issuance of such
permit, or cessation ufwork for 18odays will subject ponn�mcancellation.
|oohifythat | have read this application and state that the above information is
correct. | agree mcomply with all City, and Stam laws relating mthe building
oonstmcUon, and hereby amhnhze'mpeeentativemo/this City menter upon
the above-mentioned property for i mi `
'Signature
BUILDING PERMIT
DATE VALUATION LOT0011-014 TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER / EN61NEER
mjmRosnowo
i0m, BARD Co.
71730JAICHYAR WAY
LA QtMITA. CA 0,3253
RKLM]DESM CA 92261
(615P)341-3338 bffik 49
USE OF PERMIT
PIR RAPPROM PUNS ONLY
VALUATION Do lk�
"111 TED COST OF rRuanoly
DEMOLM 0-14 RM 101-000-423-000
TOTAL FRIOAT-r YEES ME NOW
RECEIPT
JDATE -1-BY
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
Framing
/s��
F.A.U.
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
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 Q�
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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