0205-106 (RR)LICENSED
/ hereby affirm -under penalty mperjury ma Vum licensed under provisions of
Chapter 9 (commencing With Section 7000) of Division 3 of the Business and
Professionals Code, _and ..` License is in full force and effect.
License # Lic. Class Exp. Date
OWNER -BUILDER DECLARATION
| hereby affirm undo,panonyo�po�urymau|omoxom�hnmmeCun�oom�
Contractor's
License Law for the hoUmwing�ibaoun:
( ) |, auowner mthe property, ormvemployees with wages outheir sole
compensation, will dom9work, and the structure is not intended moffered for
sale (Sec. /v44.uuvmeoomrromnumna/xC000/. _
( '>|, as ow6o, of the pmperty, am exclusively oomraodno -with, I iconsed^
contractors -to Construct the project (Sec. 70*4. Business u Professionals
Code). .
I am exempt under SectionCfor this reason
Date. Signature. of Owner
VOR'KER'S"COMPENSATION DECLARATION
i hb9 affirm U .a|ly of' 4 iY one -�fmo following declarations:
T have and will -maintain a certificate of consent t6 self -insure for workers'
compensation, as provided foi by Section V00 of th� 6bor Code, forAhe
performance ofthe worV-,fo.r ��Hch4his permit is issued.
permit is issued 'cnmo a policy wu�nre: '
.comer`D1����/�� ' '�m�Ywv o4��y�80i�6y
,
(This section, need not be completed if the permit valuation is for $100.00 or less).
.1 certify that in the performance of the wo�k for which this permit is i�ssued,
. .
shall
�—^
workers' compensation laws of California, and agree that if I should become'.
Subject to. the . workers'. compensation provisions of Section: 3700'of thpiLl. Jor
/Code, I shall forthwith, comply with those provisions.,
Date: Applicant
Warning:'Failure to secure Workers' Compen0dtid.n,.c6vdrage- is unlawfu`1 and
shall subject an employer to"criminal penalties and civil fines up to $100,000, in
additicin io.the cost of compensation, darriages asL p!ovided for in Section 3706'
of the Labor Code, interest and attorney's fees.
IMPORTANT Application mhereby made mthe Director mBuilding and Safety
for a permit subject to the conditions -and restrictions om forth on his
application. —
1.Each person upon whose behalf this application ismade & each person oo
whose requestond for whose benefit work isperformed under mpursuant to
any permit issued oaaresult o/this oppncamnagrees to, ushall, indemnify
& hold harmless the City mu^Qumta. its officers, agents and employees.
o.Any permit issued auaresult o/this application becomes null and void if
work. is not commenced within, 180 uoyu from date of issuance of such
permit, o,cessation ofwork for 18Odays will subject permit to cancellation.
| certify that | have read this application and state that the above information ia
correct. | agree tocomply with all City, and State laws relating mthe building
ounstmction, and hereby authorize representatives of this City to anm, upon
the above-mentioned property for..,in.spection
purposes:" -
Signature VJ*nodxgonV Dam '
— '
DATE LOT TRACT
VALUATION 'I
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER EN61NEER
1.7
USE OF PERMIT
I
Ek
_t _�
-
CITY UFLAWNTA
14
RECEIPT
DATE
BY
DATE F NALE)
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
-
Final '7��'/ l�d� _ _ —
I, /n�
BLOC14iNALL APPROV,V.S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
_
Equipment Location
_
Underground Electric
_
_
Underground Pibg. Test
i
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
—
Electric Final
Waste Lines
Water Piping
Heater Final V�
Plumbing Final
_
Plumbing Top Out
Equiprnent Enclosure
Shower Pans 1
—�!
G.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection _ —
—" .'—'--•---�..-�--.-`~.`-
Encapsulation
_ `_
Gas Piping
Gas Test
i
Appliances
Final -
-` — --
Final
COMMENTS:
Utility Notice (Gas)
1 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)