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Home My WebLink AboutB2004-0289 - PermitsCity of Newport Beach Building Department CIP Permit No: B2004-0289 PO Box 1768 Newport Beath, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 Job Address: 1 HOAG DR Bldg:1 Floor: Suite: Inspector Area: 7 Owner: HOAG MEM HOSP Address: 1 HOAG DR NEWPORT BEACH CA 92658 Phone: 949-574-4467 Applicant: RINELLA NEAL Address: 2220 UNIVERSITY DR NEWPORT BEACH CA 92660 Phone: 949-574-1325 Code Edit : 2001 Type of Construction: Occupancy Group: Added /New sq.ft. Bldg: Added /New sq. ft. Garage: No of Stories: No of Units : Bldg Sprinklers: Flood Zone: Issued Date: 01/12/2005 VN B 780 1 Y X Legal Description: Contractor: Address: Phone: Description of Work: COMM ADDN 780 SF (BLDG 2/OUTPAT SURG CTR) 0216-2004 MILES 8. KELLEY CONSTRUCTION COMPANY INC 1102 E VALENCIA DRIVE Address: FULLERTON CA: ; , • 714-773-9272 - - Phone: Con State Lic: 312206 Lic Expire: 02/28/2005 Bus Lic: BT00018695 ^ Lic Exp Date: 12131/2005 Worker's Compensation Insurance Carrier: STATE COMP Policy No: 1679210 Expire: 01/01/2006 Building Setbacks Rear: Front: Left: Right: Use Zone: Parking Spaces: Architect: RINELLA NEAL 2220 UNIVERSITY DR NEWPORT BEACH CA 92660 949-574-1325 State Lic:CO21102 Engineer:, TAYLOR WILLIAM C 'Address: - 2220 UNIV DR #200 NEWPORT BEACH CA 92660 Phone: 714/574-1323 State Lic:S-000702 Designer: Address: Phone: Special Conditions: Construction Valuation: $600,000.00 Building Permit Fee : $3,178.00 Plan Check Fee: $2,288.16 Supplemental: 50.00 Investigation Fee: $0.00 Energy Compliance: $296.00 Fair Share: $0.00 PROCESSED BY: ZONING APPROVAL• GRADING APPROVAL : Record Mgmt: Excise Tax: Park Dedication: SJH Trans: San Dist: CA Seismic Safety: DYsabl-d Access: $136.00 $163.80 50.00 50.00 $526.50 $126.00 $518.00 TCT • f FEE : $10,797.97 / z-. to FEES Hazardous Mat: $22.00 Add Fire Dep HMQ: $0.00 Other Fee: $0.00 Planning Department Counter Rev: $0.00 Zoning Plan Ck: $210.00 OT Plan Ck Fee: $0.00 Fire Department Fire Inspection Fee: Fire Plan Review TOTAL PAYMENT : $3,203.42 TOTAL DUE : $7,594.55 PLAN CHECK BY: APPROVAL TO ISSUE: PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION $2,224.60 $915.26 APPROVALS DATE BY COMMENTS FOUNDATION: WATER QUALITY BMP'S ROUGH GRADE INE & GRADE CERT/SETBACK ERECTION PADS FOOTINGS ?SLAB ON I GRADE DELI AR ATION OF COm PLIANCE WITII CODE OF rrnrn.LL REGULATIONS PART 6I (IF TITLE 40 AnLAvNI) RULE 14113. FRAMING: DECK SLAB SUBFLOOR ROOF & BUILDING HT EXT. SHEAR/HOLD DOWNS GENERAL FRAMING FIREPLACE THROAT !o, INTERIOR & EXTERIOR INSULATION DRYWALL SUSPENDED CEILING SHOWER LATH 7 8 0 1 SUBMITTED \SIIESTOS NOTIFICATION TO: nLNA A1QNID cflEFTOS NOI II-IL,\TION IS NOT APPI IC An LC TO rR UNUSED DEMOLIT2 4' SICNATUIL elf-- r—C-f t.',QC <i f/OL - aN .s / "'kn.-to-roc) L.0 r Giw4 At-- -IS-0 4qw, tau-5 Ow 1..4O ► EXTERIOR LATH SCRATCH (PLASTER) (2 DAY) MASONRY PRE -GROUT Ad LA- to sr'r t7t04 Sd/!8 tei OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE FOLLOWING REASON (SEC. 70315. BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER. IMPROVE, DEMOLISH. OR REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE 15 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING WITH SEC. 7000)0F OIV. 3 OF THE BUSINESS AND PROFESSIONS C00E1( OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED 0) 0 AR5 (3500): ❑ I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK, AND THE STRUCTURE 15 NOT INTENDED OR OFFERED FOR SALE (SEC. hMN. BUSINESS AND PROFESSIONS CODE. THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLETION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALEI. ❑ 1. AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044, BUSINESS AND PROFESSIONS CODE'. THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A DONTRAOTORISI LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW 1 LICENSED CONTRACTORS DECLARATION 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 BUS:NESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LIC. NO. 31 20 LICENSE CLASS �L DATE % \T \ h CONTRACTO WORKERS' COMPENSATION'15ECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION, A5 PROVIDED FOR BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. A, I HAVE ANO WILL MAINTAIN WORKERS COMPENSATION INSURANCE. AS REQUIRED BY CJ/u/ /Cir SECTION 3700WXI OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WH ICH („� �� THIS PERMIT IS ISSUED, MY WORKERS COMPENSATION INSURANCE CARRIER ARD POLICY MISC. INSPECTIONS: PERMIT EXTENSION 1ST EXP. LETTER 2ND EXP. LETTER BUILDING FINAL CERTIFICATE OF OCCUPANCY TENANT NAME: TYPE OF BUSINESS USE: OWNER / BUILDER AGENT INFORMATION NAME: ADDRESS: DRIVERS LIC. NO. MBER NNE: CARRIER POLICY NUMBER (I HIS btu II VN NLEU NU I tit LUM1tE ILO 11 I Mt HLMMII IS HUM VNt MUNUMLU PLUMS (S1001 OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 5O AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA. AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE, I SHALL FGRTHW ITH COMPLY WITH THOSE PROVISIONS. WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE (5 UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TC CRIMVAL xENN TIES AND 'IVIL FINES UP TO ONE HUNOREO THOUSAND DOLLARS (3100.000). IN AO011.3.1 :0 :.1- COST OF COA.PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37050F THE LABO.( COD., IN, ERGS. AKO ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (5EC.3007. LENDER'S NAME, LENDERS UNDRESS I CE,.1... 1HAI I HAVE DEAD ➢..5 APPLIC..PON PAO 51ATE H1AT THG ABOVE INFOHMA NON IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER U' • THE ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES. YL:�Qa) '6\C'1-W � SI .NAIIIHF OF PFMIII IFF /A �J DAIS /an Monika\Forms\BIdg Permit(Back)3/04 r City of Newport Beach Building Department PLUMBING Permit No: P2004-0159 PO Box 1768 Newport Beach, California 92658-8915 Job Address: 1 HOAG DR Bldg: 1 Floor: Suite: Inspector Area: 7 Code Edit 2001 Legal Description: Owner: Notes: Address: Phone: HOAG MEM HOSP Contractor: 1 HOAG DR NEWPORT BEACH CA92658 949-574-4467 A Issued Date: 01/12/2005 Processed By: WLiu Address: Phone: Con State Lic: Lic Expire: Bus Lic: Lic Exp Date: Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 fr Description of Work:PLUM/COMM ADDN (BLDG 2/OUTPAT SURG CTR) B2004-0289 MILES & KELLEY CONSTRUCTION CO 1102 E VALENCIA DRIVE FULLERTON CA 92831 714.773-9272 312206 02/28/2005 BT00018695 12/31/2005 Inspector /moo/N7 4c Bathroom Fixtures Toilet: 2 $18.00 Bidet 0 $0.00 Urinal 2 $18.00 Bath Tub: 0 $0.00 Shower Stall: 0 $0.00 Wash Basin: 4 $36.00 Hydro -Mass Tub: 0 $0.00 Floor Sink: 0 50.00 Floor Drain: 0 $0.00 KI chen Fixtures Kitchen Sink: G rbage Disp: Bar Sink: Vegetable Sink: Ice Maker. Dishwasher. Lndry?mp: Regulator. Lawn Sprinkler: S0.00 50.00 $0.00 $0.00 20.00 50.00 50.00 $0.00 50.00 Misc. Water Piping: Water Softener. Water Heater. Gas up to 4 outlets: Gas over 4 outlets: Backfow up to 2": Backflow over Y: Hose Bibb: Drinking Fountain: FEES Misc. 1 $4.00 Roof Drain: 2 $18.00 O $0.00 Grease Trap: 0 $0.00 1 $10.00 Grease Interceptor. 0 0 0 $0.00 P-Trap: 0 $0.00 O $0.00 Sewer 2 $20.00 Sewer. 0 $0.00 O $0.00 Sewer Alter/Repair: 0 $0.00 O $0.00 Sewer Abandon: 4 $84.00 O $0.00 TOTAL: $282.50 PAYMENT: $21.50 BALANCE: Other Record Mgmt Fee: Investigation: Plan Check: Issuance: Supplemental Fee: $261.00 $0.00 $0.00 $0.50 $0.00 $52.00 $22.00 $0.00 .LICENSED CONTRACTORS DECLARATION i40 /I hereby affirm under penalty of perjury that I am licensed under prowl and my license is In lull force and effect. License No: 312206 Class: Date: Contractor: MILES & KELLEY CONSTRUCTION COMPANY INC WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a cenificate of consent to self -insure for workers' compensation. as provided for by Section 3700 of the labor code, for the performance of the work for which this pemit i5 Issued. I have and will maintain workers' compensation insurance. as required by Section 3700 of the labor code. for the performance of the work fc. which thld permit it issued. My workers' conpensation insurance carrier and policy number is: Carrier: STATE COMP Policy number:1629210 E:.plre : 01/C1.:2006 (This section need not be completed if the pemit is for one hundred dollars ($100) or Less. I certify that In the performance of the work for which this permit is issued. I shall not enploy any person In any canner so as to become subject to the workers' compensation laws of California. and d agree that if should become subject to the workersor eerie pr ion fS 'on 3700 of the'ab^ I shn'l forthwV comply Wth Ihns> provisions -s\�. D '-6S Applicant Signal re: amirg: Failure to secureworkers' compensation coverage Is unlawful. and shall subject an employer to cnni al penal 5 and d Al fides Jp LJa.a htmdre' lhc..lsand dollars ($100.000). in addition to the cast of compensation.damages as provided for in Section 3706 of the labor code. interest, and attorneys fees. I hereby acknowledge that I have read this application; that the information given is coned: and that I am the owner. or duly authorized agent of the comer. I agree to comply with city and state laws regulating construction; and in doing the work authorized thereby. no person will be employed in vida.o.l of d.a .aba' -Gig of .1. state_ C Califomia relating to workmen's rve��5aatiiooninsurance. `' ry p Pennittee Name (PrintT s \CAM ��O Address: W)1. L `Jr'rxr� Dr+ &kL*eu CR- ions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions code. Approvals Sewer Water Pipe (ground) Gas Pipe (ground) Plumbing (rough) Gas Pipe (rough) Water Heater Gas PSI Test Gas Co Notified Final Inspector/Date 01Pipe (groun,,Ia 9 -05 11.931 PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VAID INSPECTION City of Newport Beach Building Department ELECTRICAL Permit No: E2004-0179 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3 Job Address: 1 HOAG DR Bldg: 1 Floor. Inspector Area: 7 Code Edit: 2001 Owner: HOAG MEM HOSP Address: 1 HOAG DR NEW PORT BEACH CA 92658 Phone: 949-574-4467 - Issued Date: 01/12/2005 Processed By: Suite Legal Description: Contractor: Address: Phone: Con State Lic: Lic Expire: 1 r r Bus Lic: W Lic Exp Date: Description of Work: ELEC/COMM ADDN (BLDG 2/OUTPAT SURG CTR) B2004-0289 MILES & KELLEY CONSTRUCTION COMPANY INC 1102 E VALENCIA DRIVE FULLERTON CA 92831 714-773-9272 312206 0212812005 BT00018695 12/31/2005 Inspector Notes: New Construction Residential Multi -Family 0 $0.00 1-2 Family 0 $0.00 Service 0-600V up to 200A: 0 $0.00 0-600V over 200A: 0 $0.00 Over 600V or 1000A 0 $0.00 Receptacle/Switch/Outlets Receptacles/Outlets: 43 Fixtures: 27 Sep Circuits: 2 Signs Branch Circuit: Each Add Circuit: Time Clocks: 0 0 0 FEES Motors/Transformers (HP/KVA) $33.80 0 to 1 HP/KW/KVA: 0 $24.20 1 tD 10 HP/KW/KVA: 1 $8.00 10 to 50 HP/KW/KVA: 1 50 to 100 HP/KW/KVA: 1 Over 100 HPMWMVA: 0 Moo $0.00 $0.00 $0.00 $10.00 $21.00 $41.00 $0.00 Piggy Back/Temp Power 0 $0.00 Temp Power Pole: 0 $0.00 TOTAL: $251.25 PAYMENT: $33.50 BALANCE: Temp Underground: Sub Panel: Record Mgmt Fee: Plan Check Fee: Investigation Fee: Issuance Fee: Supplemental Fee: $217.75 0 3 0 0 $0.00 $45.00 $0.00 $0.00 $0.50 $45.75 $0.00 $22.00 $0.00 ENS D CONTRACTORS DECLARATION I reby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencingwithSection 7000) of Division 3 of the Business and Professions code. ed my license is in full force and effect. R Date: /— '� �J Contractor MILES 8 KELLEY CONSTRUCTION COMPANY INC icetise No: 312206 Class: V ADorovals WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate d consent to self -insure fa workers' compensation. as provided for by Section 3700 of the labor code, for the peronrence of the work for which this permil Is issued. I have and will neintain workers corrpensation insurance. as required by Section 3700 of the labor code. for the performance of the work for which this pemit is issued. My workers compensation insurance carrier and policy number is: Expire Date: 01fJ:C00M1 Carrier: STATE COMP Policy number:1679210 (This section need not be completed if the permit is for one hundred dollars ($100) or less. I certify that in the performance of the work for which This perrnt is issued. I snarl not employ any person In any manner so as to become subject to the workers' compen .ii,.n laws of California. and agree that if I should become subject to the workers' compensation provisiorApf SeClion 37Q0 0f the lab bade, I shall forthwith comply with thc;r p-ovtion� Dots/ L" V3--OS wm riFailure la secure Applicant Signature :/ gworkers' compensation coverage is unlawful, and shall subject employer to crimnal penalties and civil fin ($100.000), in addition to the cost of corrpensation,darreges as provided for in Section 3706 of the labor code. interest, and attorneys fAr . I hereby acknoMedge that 1 have read this application: that the Information given is coned: and that I am the owner. or duly authorizedoetion of the aeon code 1 the i 10 of comply with city and state laws regulating construction: and in doing the work authorized thereby. no person will be err oy in California relating to workmen's comp sation Insurance. Permitlee Name (Print) Signature of pennittee:t) Address : up to one nundrer' thousand dollars 5 Rol E. Ultacirt Qr. /-(2 -Oa Date: Underground Under Slab/Floor Rough Conduit Walls Rough Wiring Ceilings Rough Sevice Temp Power Utility Company Notified Final Inspedorl0ate Grounding Electrode -OS PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION. City of Newport Beach Building Department MECHANICAL Permit No: H2004-0120 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3 55 Job Address: 1 HOAG DR Bldg:1 Floor, Inspector Area:7 Owner- HOAG MEM HOSP Notes: Address: 1 HOAG DR NEWPORT BEACH CA92658 949-574-4467 Phone: Issued Date 01/12/2005 Processed By: HVAC Items Furnaces Up to 100K BTU/hr. 0 $0.00 Over 100K BTU/hr.. 0 $0.00 Wall/Floor Heaters: 0 $0.00 Heat Pumps & Package Units Up to 100K BTU/hr.. 0 $0.00 Over 500K BTU/hr.. 0 $0.00 Up to 1M BTU/hr: 0 $0.00 Up to 1.75M BTU/hr: 0 $0.00 Over 1.75M BTU/hr.. 0 $0.00 Suite: Code Edit : 2001 Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: LIc Exp Date: Boilers & Compressors Up to 3HP: 0 >3HPto15 HP: 1 >15 HP to30 HP: 0 >30 HP to50 HP 0 >50 HP: 0 $0.00 Air Handling Units up to 10K CFM: 1 Over 10K CFM: 0 VAV Box: 7 TOTAL: Legal Description: $0.00 $22.00 $0.00 $0.00 S9.00 $0.00 $84.00 Description of Work: MECHICOMM ADDN (BLDG 2/OUTPAT SURG CTR) B2004-0289 MILES & KELLEY CONSTRUCTION 1102 E VALENCIA DRIVE FULLERTON CA 92831 714.773-9272 312206 02/28/2005 BT00018695 12/31 /2005 FEES Ventilation Bathroom Fan: Exhaust Fan: Attic Fan: Down -Draft Fan: Residential Hood: Comm. Hood: Repair/Alter/Add: fop COMPANY D re •N.SOZ r ter Ireetor (�1NGS/ «4Vt Into d-Zip-es-Iv/Pt / c.-) �1rLJf�^ SSv/Pt rC( Misc O $0.00 Fire Dampers: 3 $18.00 Gas Line: O $0.00 Metal Fireplace: O $0.00 ICB0 App. N: O 00.00 O $0.00 0 00.00 5188.75 PAYMENT: 512.25 0 0 0 50.00 50.00 50.00 BALANCE: 5176.50 Other 50.00 $0.00 Record Mgmt Fee: $0.50 Investigation: $0.00 Plan Check: $33.25 Issuance: $22.00 Supplemental Fee: $0.00 LICENSED CONTRACTORS DECLARATION I hereby affirm under penalty of perury that I am licensed under provisions of Chapter 9 (commencing with Seccjgn 7000) of Division 3 of the Business and Professions code, Approvals and my license Is In full farce and effect. ense No: 312206 Class: R Date: t'a '06 Contractor: MILES & KELLEY CONSTRUCTION COMPANY INC WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: l have and will meinlain a certificate of consent to selflnsure fee 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 have and will maintain workers compensation Insurance, as required by Section 3700 of the labor code. for the performance of the work for i)hicn _lis ,erne is issued. My workers' cortpensalion insurance carrier and policy number Is: Carrier: STATE COMP Policy number:1679210 E.:pita : 31/0 7200C (This section need not be completed if the permit is for one hundred dollars (5100) or less. certify that In the performance of the work for which this perm is Issued. 1 shall not employ any person in y manner so as to become subject to the workers' corrpensabon laws of Ca)[omia, and agree that sho Noes' to the workers' compensatioNoes' f 3700 the la co!e,l shell forthw'th crTly with "vs-i prvshns. 1-t Applicant Signature: Date: Wami n allure to secure walkers' compensation coverage is unlawful. and shall subject an employer to criminal penalties and civil Ices tip L. or.a hi ndiad t..ausa. A collars (5100.000). In addition to the cost of conpensation.damages as provided for in Section 3706 of the labor code, interest, and attorneys fees. 1 hereby acknowledge that I have read this application; that the Information given Is correct; and Nat 1 am the owner. or duly authorized agent of the owner. I agree to comply with city and state laws regulating construction: and in doing the work authorized thereby. no person will be errployed in vitiation of the abo.' .We ‘f .do stab. U California relating to workmen's co Saban insurance. r. Pemnittee Name (Print) Signature of permittee: elitILCO Address: \COL . J0A.C•u jt 01N,, Date/%-I2 OS HVAC/Hood-Rough Fireplace -Rough Gas Test Fireplace -Final HVAC/Hood-Final Inspector/Date Underslab/Floor PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION.