0205-105 (RR)N1 �`,� ,I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04"W ::Professionals Code, and my License is in full force and effect.
'O� M License # Lic. Class Exp. Date
'tiw;;� "' 511457 C39 61301033
' ,
Z ^Date`%' "� _ h Signature of Contractor��
I—•� _, *; .'; OWNER -BUILDER DECL'-I�F(ATi N ^
Ha I hereby affirm' under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
>f Z ( ) 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
i contractors to construct the project (Sec. 7044, Business & Professionals
t ' , Code).
6 ( ) i;am exempt under Section , B&P.C. for this reason
0 N Date { Signature of Owner
t ' U—tl Q fC WORKER'S COMPENSATION DECLARATION
� Z : i..� `
'Ln,Q cc,. , 1:, hereby affirm under penalty of perjury one of the following declarations:
r -F— O ,(6)1I have and will maintain a certificate of consent to self -insure for workers'
XW LLt` !compensation, as provided. for by Section 3700 of the Labor Code, for the
�O ; J Q N- performance of the work for which this permit is issued.
<,L)l , ( i I have and will maintain workers' compensation insurance, as required by
O U°Q �,SftTon 3700 of the Labor Code, for the performance of the work for which this
a Z permit is issued..My workers' compensation insurance carrier & policy no. are:
STATE PUND .` Policy No. �A4�•97-flOGS269
* c0 51
(This section need not be completed if the permit valuation is for $100.00 or less).
x f (
)',I certify that in the performance of the work for which this permit is issued,
i y V shall not employ any person in any manner so as to become subject to the
F •„ ` workers' compensation laws of California, and agree that if I should become
:K subject.to the workers' compensation provisions of Section 3700 of he Labor
ode, I shall forthwith comply with those 3pr a(sl'o �^---�-
, #
Date: ,' -hr- ° Applicant<<� ,,
it I -We
rninj): Failure to secure Workers iron 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 attomey's fees..
. 3 IMPORTANT Appllcation is'Fiereby made to the Director of Building and Safety
' for. ..a permit subject to.the conditions -and •restrictions set forth on his
,° epplicatlon. k
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 applicaton agrees to, & shall, indemnify
_• &.hold harmless the City of La Oulnta, Its officers, agents and employees.
1 Z. Any permit Issued as a result of this application becomes null and vold if
wprk Is not commenced within 180 days from date of Issuance of such
t< v permit,. or cessation of work for 180 days will subject permit to cancellation.
certity 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.
i � the, above-mentioned property for inspection purposes.
•{�i T
1 �, '.Signature (Owner/Agent) �'f
Date T
BUILDING PERMIT, r°"MII 94 t ;:
/ Ong -ice'
DATE �• / - WALUATION y Ki LOT TRACT
JOB SITE i
ADDRESS DLDG..11 0AX 1JJ.F.vJ
5?/ -3 -0/
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PGA W.F1111r iti�#f1►'r v 1TAL 110MECtL=Tl�a'iMS
. D OF C°J9,MRNrA1NC,.
P.O, FOX l 000
671 X555 V45T PALM CMYON J7RTV 3
LA QUIVITA
C,@ITIL-DRAL CrYY Cly. 92,262,
(lt,1Jl'Jd5'•9111 CBII# 4611
USE OF PERMIT
(3MF1 kAL BU.[MLNO
RE-111001?WITH C:I.AS,S.A VIA7'ER AL -3, .fI D0. 11: 54.337, 54,1A
ii.&E.OA.7ION o,944.nU ):3
X51'T.Iv1.NYU) COS"f OTS' (10P
2, 2.�'It'rdA)
yy�; �y��T•,�'�Q , t
A"1t4�.0i:cyL PLJi3�YAJl7i 7!P
Rk?ROOF r,IT, 301.0001418-0M f?tF,of
WY OF LAQUINU
FINANCEDEF"
3D*A,41`OfALt CON."P it:UCr O:bf AND, PAN ( HF.CCC
-
0.t1t1
L&N, PIM-PAM.M.5
$0.00
TOTALtPFERAU ' PXFS DIM, NOW
V01100
4
RECEIPT
DATE/(. )
B
DA FIA
oil
I PEC
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
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 APPROV S
Steel
POOLS - SPAS
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��G(�
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: