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LICENSED CONTRACTOR DECLARATION
I hereby affirm 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'�'�tss`sj� Exp. Date
i2aiy7
,.'Date Signatureof Contractor 1 t �,� r `•rl ,
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason: i -
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not 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 Signatureof Owner
WORKER'S COMPENSATION "DECLARATION E
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintain a certificate of consent to seN-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
( ) 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 Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
() I ceitli thAtlWIMbaperformance of the work for whkA%iisl` trmlt 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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply withjtho provisions. j
/Date: '7%f� 1�1�� Applicant %aij . (n a�l�if'
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this application agrees to, &shall, indemnify
& hold harmless the City of?Indian4ell's4itiMicers, agents and employees.'
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signature (Owner/Agent) ,�,��wft��-!�;w.�- Date
ALC 'BUILDING PERMIT PERMITS
4iR.ib7_1 �ftd
DATE 3/ I/96 1
VALUATION MI1,684.,(4. LOT 21 TRACT 2.3913 P14A81.1V
JOB SITE ADDRESS APN
OWNER
41fhr:il(4 l"t,ri';1 i i744c7 r71�r d?n SCI PtiI
41965 EuARDWAL M2
PAla&I D FSER'i C•A. 922.! i
(619'1777-77%fi
USE OF PERMIT ,
f S1Nt Lf.I-AAHLY W1.I,.LINr
PLAN 3 '
R(Xi l R SNELL1',N131aROF� R.&AISSCK3.
4 1 °6S
.Prm"M OISI ERT CA 9221'
'1`FiAC T C,(.>iJ3'f'ftLjC1'10N 2'(45.00 Si?
0ARA.00C'ARPORT G3h.G0 SF
FMIA$ATED C ST tai' t' ONST.RUC ION
('E(tM(T FEE SUMMARY
PLAN04F.CK rhl?
101-000-439-318
5-197
t;C3N 1'Ct.1J(" ION 11- X7 ,
101-000418-0f10
$716
1V1ai¢.`.:HAMC:AL PPE
101-000-42i-000
W
Pf ECTRICA1, iV.F.l
101 -000 -420 -OW
Si31
PGLWiING 171T,
3 01-194'0~41,m•(3C1()
3154
ST ONG X10TION TION FIT, - .R&SID
101-()00-241.-060
S.12
ORAT)INO FEE
101-000-423-000
$20
1NFRASTRIX11)RE.FEE
225-000443-342
$2.737.
ART 1N Muffi ,rC K.,kCF-3 - RBSM 701-(X111-255-000 _.
$54
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17
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89
21
1,21,684.10
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S1J&TO'1'AL C4.«i*aSMVCMiV AND LAN CHR"K, � i r, SM7633
LESS PRE -PAW PIES $0.0()
'I?'i)•M PEMPI' M8 TiU1 NOW 1 $076,$13
IRECEIPT i� IDATE IBY
1c,
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck �%y
Exhaust Fans
_
O.K. to Wrap
F.A.U.
-Framing
Compressor
Insulation M1.
Vents
Fireplace P.L. JL
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL P ROVALS
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
Sewer ConnectionEncapsulation
Pool Cover
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVALS
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: