0205-092 (RR). ^LPA"°..vm
I- hereby uffinn under penalty of perjury that | am | , provisions of
Chapter �ith of Divisibin 3 o the Business and
Professionals Code, and myLicense iomfull force and effect.
uommw uc.o/ma Exp. Date
�-
/"°te--��f~�~�-- Signature of Contractor—
OWNER-BUILDER DECLARATION
°'=^^OVVNER-BmLDERDECLARATION
nemUy��affirm penalty y mmtho Contractor's
License Law,fu,the following reason:
( ) | as,owner ofVm with their
compensation, will do the -work, and the structure i's . n6t intended or offered for
sale (Sec. 70.44, Business & Professionals Code).
1, as owner, of he.propdrty, am exclusively contracting with licensed
contractors to construc . t V We'project (Sec. 7044,� Business & Professionals
Date Signature of Owner
WORKEKS'COMPENSATION DECLARATION
I hereby affirm under,06nalty of.perjury one of the' following declarations:
compensation,` as. prbvi _r'Code, for the
perfoiman*Ce of the 'work for which this Oermiris iss6ed.
(-J-1-have andwill.JM'aintain w . orkers . ' compensation insurance, as required I by
.(This se6ti�h nbe'd not. -be Completed if the permit valuation is for $10 , 0.0 , 0 or less)...
I shall not _em�i6 y- any'� p�ri or:n':in any Tanner so as �to, become subject -to the
workers' compensation laws of.Calif6rhia, and agree that if I should,become
subject to the workers' comp6hsation,.p�qyjsions of, Section.'. 3,700 of 4he Labor
Applicant
of theiabbr Code, interest and attorney s4ees.
for 'a permit subject to the conditions and restrictions set forth on his
1: Each person upon whose behalf this application is made & 'each person at
whose request and for whose benefit work mperformed under mpursuant m
any permit issued ao� mouhofthis appnoumn agrees to, & shall, indemnify
& hold xa,m|ovumoCitymuuQuinm. its officers, agents and employees.
2. Any permit iuvuau as u ,voun o/this application »aoomwv nun and void if
wm,x is not nvmmonoou within 180 days from date of issuance o, such
permit, or cessation oxwork for 1aodays will subject permit to cancellation.
|oortify that | have read this application and state that the ubo" information
correct. | agree to m
oop|ywitn CitCity,xa�and State laws relating mthe building
oonutmohon, and hereby authorize representatives o/this City toenter upon
the above-mentioned property for inspection Pu,Poopo.
Signature (Owner/Agent)
Date
BUILDING PE MIT
DATE ,VALUATION LOT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER EN61NEER
USE OF PERMIT
RECEIPT
DATE--
BY
DAT
INsP b
OPERATION
DATE
INSPECTOR OPERATION
DATE I '.INSPECTOR
i •
BUILDING APPROVALS
� MECHANICAL APPROVALS
t Set Backs
Underoround Ducts
Forms & Footings
Ductsy
Slab GradeRetum
Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
i
v�O
Q. K. to Wrap
I F.A.U.
I Framing ,
Compressor
Insulation !
--'
Vents
rireplace P.L.
Grills
!
Fir solace T.O.
Fans & Controls
j
Par',y Udall Insulation
Condensate Linen
' Warty Wail Fire'rra!! ,
I
Exterior Lath
Dn vall - Int. Lath —_ --1—,—
--
--� i
21 Final
Eir+at
j ---
POOC_ o PAG
BLOC'IVIVAL APPROVALS
Se: sacks
—
Electric gond
;
Foctings _ j
Main Drain
--
Bor.-4 Beam j
! Approval to Cove,-
! Fnuia:rent Location
Und_e~_round ElectnnI—
_
Under round Pibg. Test.
PL{rIN��.'+'.01�
�Ga..Test
ones
j Elecine F,ra![`.Gaste
'--
Water Piping � _ —�-
- i Piurribt^-, Final
-
1
--r-- —
Piumbinc Top Cu= s
7--
! �g.,,cm;;n Enclosure
I
-- ---�—
I Shower Palls:.!:
rC--_— -� _
i`P'/!ei
°,;' F;nish PI8£?E'
— ----•--
`--
•' -------- --�—
Lateral 1
+ t'D(S; ..•ti4+Fr
Cav/f3i CC.'.nGc:!Cri —_ •._.�-._ .__.,.-.- .-._-
___ _....—. _ :.�r••�i:!ailUSt .-_
1
�._—; ._ --. y
Piping
as
Final-
I Utility Noti_e'Gas) I
_J
ELECTRICAL APPROVALS1
1
_
Temp. Powe; Pole 1-~'
tr„ Conduit —�—(
_! eraround
r Rough ;^Bing _t
'
Low pottage Wiring
t Fixtures
Main Sery-e
Sub Panels -t- —
—
Exterior Receptacles--.
—
G.F.I.
—�
t Smoke Detectors
Temp. Use of ?ower
Final
--
Utility I;otice (Perm)
L. --'� - -