0205-111 (RR)LICENSED CONTRACTOR DECLARATION
| hereby affirm under penalty ofperjury that |omlicensed under provisions of
Chapter (commencing with Section 7000) or Division 3oVthe Business and
Professionals Code, and my-Ucmnxoioiofull force and effect.
uoonvvw uv.mvnx Exp. Date
�/Signature of Contractor
`
OWNER -BUILDER.
affirmI hereby thatam exemptfrom the Contractor's
License Law' for the following reason:
I', as owner of th6'-property, or my',employees with wages as their sole
compensation, will do the.,Y�ork, and the'sitructure is not intended or offered for
sale (Sec. 7044,BUsiness & Prof ession6lS, Code).
1, as oWner of the, property, am'exclusiV61y contracting with -'licensed
co,ntractors.to construct"the project (Sec. 7.044, Busir�esS & Professionals
I am exempt.under Section B&P.C. for this reason
Date Signature. of Owner
I hereby affirm' under.pe . nalty. of perj . 4ry. one of the following declarations:
I have and will maintain aCertificate of consent to selfririsure for workers'
compensation; as provided for by Section 3700 of the' Laboe Code, for the
performance of the work for which this permit is issued.
1 have -arid..Will maintain workers. compensation insurance, as requir,eld. by
Sktibrf 3760 'of thp Labor Code, for thd performance.of th6'work for which this
permit- is issued. My Workers'. compensation - insurance carrier & policy no. are:
Cahi6r,, Policy No.
(This section need not.beldomoletedif the permit valuation is for $100.00 or less).
I certify-tha . t in 'th� �erformanc'e of the Work for which this permit is issued:
I sl�iall not employ any person in . any manner so as td,become subject to the.
subject- to the Workers', compen�ation-.P�6vi.g.iohs6f,Section' 3700 of:the, . Labor
Code, fihall forthWi , th comply wit . h those provisiohi� "i.?
,,.-Date: ApplicanE
Warfi,ing:. Failure to secure Worker!3',Corrio6n§atiQk06i)-b-r-i'66-�i.i-.b�WlawfuI and
shall �6bfectan employer to criminal 0e1&ti6§- Y'il fines up'to $100,000, in
of the Labor Code, interest and attorney's fees.
Application is hereby made tothe Director ofBuilding and '
for a permit subject to the conditions' and restrictions met forth onhis
application.
1. Each person upon whose behalf this application is made &each person at
whose request and for whose benefit work is performed under orpursuant m
omyponnhissued aoaresult nfthis app|icamnogmeo�o.ashall, indemnify
& hold harmless the City oVLoOuinta. its officers; agents and employees.
2. Any permit issued as.a result o/this application becomes nv|| and void if
work is not commenced within 1e0 days from date o, issuance of such
pormit, or cessation ofwork for 180 days will subject permit to cancellation.
|oertify that | have read this application and state that the above information ix
correct. | agree tucomply with all Qty, and State laws relating mthe building
construction,d hereby authorize representatives ofthi Citymomo,upon
the. above- mentioned property for inspe�qtion purposes.
Signature —� '
BULDINGPERMIT
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER F:Nh'NrF:R
A.
USE OF PERMIT
RF
MAY
FINANCEDE
RECEIPT
DATE
By
DATEZF NAL
"SIT
1
. mml to
I
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 �v / l�2
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 �f�(��U�
BLOCKWALL APPROVAL:
Final
POOLS - SPAS
Stee!
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
I
Final
COMMENT S:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit —�
Rough Mage — --�
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles !
G.F.I.
Smoke Detectors _
Temp. Use of Power
Final
Utility Notice (Perm)