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Home My WebLink AboutB2004-0130 - PermitsCity of Newport Beach 61/ 1/7gsG3-z Building Department CIP Permit No: B2OO4-0130 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 Job Address: 1 HOAG DR 13Idg:1 Floor:1 Suite: Inspector Area: 7 Legal Description: Description of Work: TENANT IMPROVEMENT 2363 SF (1ST 8 3RD FL CONF CTR) 0094-2004 Owner: HOAG MEMORIAL HOSPITAL Contractor: WATSON INV DEVELOP Architect: WOOD III JACK F Address: ONE HOAG DR Address: 18182 SERRANO AVE Address: 4850 BARRANCA#203 NEWPORT BEACH CA 92658 VILLA PARK CA 92867 IRVINE CA 92604 Phone: 949-574-4477 Phone: 714-832-1191 Phone: 949/552-2061 State Lic:C015130 Applicant: WOOD III JACK F Con State Lic: 436023 Engineer: Address: 4850 BARRANCA#203 Lic Expire: 03/31/2005 Address: IRVINE CA92604 Bus Lic: Phone: 949/552-2061 Lic Exp Date: Phone: State Lic: Code Edit : 2001 Worker's Compensation Insurance Designer: Type of Construction: 11-1 HR Carrier: STATE FUND Address: Occupancy Group: B Policy No: 229-0019928 Added /Newsq.ft. Bldg: 2362 Expire: 01/01/2005 Phone: Added /New sq. ft. Garage: No of Stories: 3 Building Setbacks Rear: / Special Conditions: HOAG No of Units : Front: / Left: / Right: / Issued Date: 02/24/2004 Use Zone: PC Parking Spaces: /spec/ O� Construction Valuation: $75,100.00 Building Permit Fee : $725.60 Plan Check Fee: $522.43 Supplemental: $0.00 Investigation Fee: $0.00 Energy Compliance: $0.00 Fair Share: $0.00 PROCESSED BY: ZONING APPROVAL: GRADING APPROVAL : Record Mgmt: $55.00 Excise Tax: $0.00 Park Dedication: $0.00 SJH Trans: $0.00 San Dist: $0.00 CA Seismic Safety: $0.00 Disabled Access: $75.10 TOTAL FEE : $2,169.52 FEES Hazardous Mat: $22.00 Add Fire Dep HMO: $0.00 Other Fee: $0.00 Planning Department Counter Rev: $0.00 Zoning Plan Ck: $52.50 • •:02 Plan 26 Gee: $0.00 TOTAL PAYNMNS7••4246.60 TOTAL DUE : $1,882.84 • • .• • �•• �• ••„ PLAN CHECK BY: OO • ' ' • • • • ' APFROVa1_41:90 : •• ••• •,• PERMIITS EXPIRE 180 Di-'4Y9 AFf &R'JSSU4 NCE,OR 114 ST VALID INSPECTION • • • • • • • • • •• ••• •• • Fire Department Fire Inspection Fee: Fire Plan Review at_ or $507.92 $208.97 ca) 1' )filod APPROVALS [ DATE FOUNDATION: BY COMMENTS WATER QUALITY BMP'S ROUGH GRADE LINE & GRADE CERT/SETBACKS SLAB ON GRADE Apr1ARATIDM OF CON?L' ='CE NIT. CCOE OF FEU'c.".AL PECIULAT1NS PART 61 OF TITLE 40 A7 Fat+T RULE 1.0s. — n• 1 •'wr 1rr1:7 NOTIFICAT;CAL 'T0: U U24 0 PC. M' 1T IFICAT ION IS NOT FRAMING: DECK SLAB A PPLICk '_.: NO d'NOYUSW 1:111Lvt.l i SUBFLOOR ROOF & BUILDING HT EXT. SHEAR/HOLD DOWNS GENERAL FRAMING FIREPLACE THROAT INTERIOR & EXTERIOR INSULATION DRYWALL SUSPENDED CEILING SHOWER LATH SIGNATURE: Iniaq 5 IIG/ Prig Le oi• ////e/�-s•� ,ryJ'�B/i1A1J/A®, EXTERIOR LATH SCRATCH (PLASTER) (2 DAY) MASONRY PRE -GROUT OWNERMUILOER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I M1 EXEMPT FROM THF.ICONRUCTORS LICENSE LAW FOR THE FOLLOWING REASON (SEC. 7031,5, BUSINESS AND PROFESSIONS WOE: ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER. IMPROVE DEMOLISH, OR REPAIR ANY STRUCTURE. PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SJCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LICENSE LAW (CHAPTER 9 (COMMENCING WITH SEC, 7000) OF DIV. 3 OF THE BUSINESS AND PROFESSIONS CODE)) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 70315 BY MTV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TOA CIVIL PENALTY OF NOT MORE THAN FIVE HUMORED DOLLARS (55M): ❑ 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 AND PROFESSIONS COOS: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO 00ES SUCH WORK HIMSELF ON 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 SOD WITHIN ONE YEAR OF COMPLETION, THE OWNER -BUILDER WILL HAVE THE BL OEN N OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF S5.L I. AS OWNER OF THE PROPERTY, NM 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 CO TRACTORNILICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW.). I MI EXEMPT UNDER SEC. B.B P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I MI LICENSED UNDER PROVISIONS OF CHAPTERS (COMMENCING WITH SECTION 7000) CF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSECLASS LIC. NO. /� ' %{ pATE 1• IU'l • 04 CONTRACTOR /iQ J tigh WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF'NSOIE FOR WORKERS' COMPENSATOR, AS PROVIDED FOR BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORKMNCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. QLR/Y MISC. INSPECTIONS: PERMIT EXTENSION 1ST EXP. LETTER 2ND EXP. LETTER BUILDING FINAL CERTIFICATE OF OCCUPANCY •• • • ••• • • • • • • • • •• ••• • • • •••' TENANT NAME: TYPE OF BUSINESS USE: Monika\Forms \BldgPermit(Back)10\03 • ••• ••• •• • • • • • ••• ••• • •• •• • • •• • • • ••• • •• • • • • • • • • • • • • • • • • • ••• • • . •• • • • • • •• •• • • ••• • • • •• ••• • ••• •• 1 HAVE AND WILL MNNTMN W/VYFRS' COMPENSATION INSURANCE. AS REQUIRED BY SECTION 3700 OF THE LABOR 000E, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER (IHI5 sec IVN NttU NUI VI UUM'LGItU IF I Ht YEHMl I IS HINT UNt HUNUNtU WLLAHS MOO) OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED. I SHALL NOT EMPLOY ANY PERSON W ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SEC•TIO1N 37,0 OF THE LABOR 000 SHALL FORTHl'XMNITH COMPLY WITH THOSE PROVISIONS. 1 OATF• .•vat APPLICANT::, WARNING: FAILURE TO SECURE WORKERS' COMPENSATOJ COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ARO CIVIL FINES UP TO ME HUNDRED THOUSAND DOLLARS (5103,000), IN 4001110N TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENOING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC.3097, CN.C.). LENDER'S NAME LENDERS ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 15 CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS CW NTYJ6ENTER UPON THE ABOVEIMENTIONED PROPERTY FOR INSPECTION PURPOSES. (t cM No-t-\Jc PERMLTTEE e NAME (PRINT( I /GALL Waljel-. 5 GNATURF OF PERM IFi ).-1.9 • et-i PATE City of Newport Beach Building Department MECHANICAL Permit No: H2004-0054 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 Job Address: 1 HOAG DR Bldg:1 Floor: 1 Suite: Inspector Area:7 Code Edit : 2001 Owner: Address: Phone: HOAG MEMORIAL HOSPITAL ONE HOAG DR NEWPORT BEACH CA92658 949-574-4477 Issued Date 0212a1 Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: Processed By: `-' Lic Exp Date: Legal Description: WATSON INV DEVELOP 18182 SERRANO AVE VILLA PARK CA 92867 714-832-1191 436023 03/31/2005 Description of Work: MECHITENANT IMPROVEMENT (1ST&3RD FL CONF CTR) B2004-0130 /nspecto of 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 to1MBTUhr: 0 $0.00 Up to 1.75M BTU/hr: 0 $0.00 Over 1.75M BTU/hr: 0 $0.00 Boilers & Compressors Up to 3HP: 0 >3 HP to15 HP: 0 >15 HP to 30 HP: 0 >30 HP to50 HP 0 >50 HP: 0 $0.00 Air Handling Units up to 10K CFM: 0 Over 10K CFM: 0 VAV Box: 0 TOTAL: $0.0a $0.00 $0.00 $0.0o Woo Mao $0.00 FEES Ventilation Bathroom Fan: Exhaust Fan: Attic Fan: Down -Draft Fan: Residential Hood: Comm. Hood: Repair/Alter/Add: M isc $0.00 Fire Dampers: $0.00 Gas Line: $0.00 Metal Fireplace: $0.00 ICB0 App. #: E0.00 $0.00 $60.00 $108.75 PAYMENT: $17.25 0 0 $9.00 $0.00 80.oa BALANCE: $91.50 Other $0.00 $0.00 Record Mgmt Fee: E0.50 Investigation: $0.00 Plan Check: $17.25 Issuance: $22.00 Supplemental Fee: $0.00 ICENSEDCONTRACTORS DECLARATION /QLi.d eregy affirm under penalty of penury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions code, and r f)ieense is in full force and effect. o:436023 Class: Date'<1-1'-o`t Contractor : WATSON INV DEVELOP WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure far workers' compensation, as provided for by Section 3700 of the labor code, for the performance of the work for ich this permit is issued. ve and will maintain workers compensation insurance, as required by Section 3700 of the labor code, for the performance of the work for which this permit is issued. rkers' compensation insurance carrier and policy number is: • • • • • • • Carrier: STATE FUND Policy number:229-0019928 Expire : 01/01/2005 • • • • • • • • • • • (This section need not be completed if the permit is for one hundred ddlars ($100) or less. • • ••!• ••, • I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as tE ggc4tnerubaale l toohiprkers' compensation laws of C9alifornia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of yie)labor code, I shall forthwith comply with those provisions. Z•24- 04 Applicant Signal e: arning: Failure to secure workers' compensation coverage is unlawful, and shall subj el an employer to crarinal psnalyesailil fivirh}ts up t one hl&IMrEd thdG4a:d Q?11aw ($100,000), in addition to the cost of corrpensation,damages as provided for in Section 3706 of the labor cod•sl,•ndattpmey9fees. • • • • • • • • • • • • • • • • • • • . • . • • • • • • 1 hereby acknowledge that 1 have read this application', that the information given is correct; and that 1 am the Queer, r, duly a•thorize� agent of tie owrrr. 1 agreotto • comply with city and state laws regulating construction, and in doing the work authorized thereby. no person will be employed in violation of the labor code of the state of California relating to workkmfn's compensation insurance. Permittee Name (PI n7t) al cc.(Lp A.A.trC34r' Address: • ••• ••• ••• •• • Signature of permittee: • • • • 1 • }jt. . ••2-1M•o�l • • • • ♦ •• •• • Approvals Underslab/Floor HVAC/Hood-Rough Fireplace -Rough Gas Test Fireplace -Final HVAC/Hood-Final Inspector/Date s-/n/y,- PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION. V' - t�1 �f • . City of Newport Beach Building Department PLUMBING Permit No: P20040079 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 Job Address: 1 Inspector Area: 7 Owner: Address: Phone: HOAG DR Bldg: 1 Floor: 1 Suite: Code Edit 2001 Legal Description: HOAG MEMORIAL HOSPITAL ONE HOAG DR NEWPORT BEACH CA92658 949-574-4477 Issued Date: 02/24I2A04_ Processed By: - /7 Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: Lic Exp Date: WATSON INV DEVELOP 18182 SERRANO AVE VILLA PARK CA 92867 714-832-1191 436023 03/31/2005 Description of Work:PLUM/TENANT IMPROVEMENT (1ST&3RD FL CONF CTR) B2004-0130 Inspector N tes: ®w� Bathroom Fixtures Toilet: Bidet Urinal Bath Tub: Shower Stall: Wash Basin: Hydro -Mass Tub: Floor Sink: Floor Drain: $0.00 So.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Kitchen Fixtures Kitchen Sink: Garbage Disp: Bar Sink: Vegetable Sink: Ice Maker: Dishwasher: Lndry/Trap: Regulator: Lawn Sprinkler: $9.00 $9.00 S0.00 E0.00 $0.00 $0.00 $0.00 50.00 $0.00 Misc. Water Piping: Water Softener: Water Heater: Gas up to 4 outlets: Gas over 4 outlets: Backlow up to 2": Backflow over 2": Hose Bibb: Drinking Fountain: FEES $8.00 $c.90 $0.00 $o.00 So.00 $0.00 So.00 $0.00 $0.00 TOTAL: $55.00 PAYMENT: Misc. Roof Drain: Grease Trap: Grease Interceptor: P-Trap: Sewer Sewer: Sewer Alter/Repair: Sewer Abandon: 0 0 0 0 0 0 0 $6.50 BALANCE: So.00 So.00 0 $0.00 $0.00 Soo() $0.00 Other Record Mgmt Fee: Investigation: Plan Check: Issuance: Supplemental Fee: $48.50 S0.o6 $0.00 $0.50 $0.6o $6.50 522.00 $0.00 LICECONTRACTORS DECLARATION er by aRrm under penalty of perjury that 1 am licensed under provisions of Chapter 9 (conurencing with Section 7000) of Division 3 of the Business and Professions code, my It�o nse is in full force and effect, nseNe. 436023 Class: (17 Date: x 1-111• DM Contractor: WATSON INV DEVELOP WORKERS' COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of the following declarations: I have and will maintain a certificate of consent to self -insure fa' workers' compensation, as provided for by Section 3700 of the labor code, for the performance of the work for I.Kwhich this perntit is issued. V� I have and will maintain workers' compensation insurance, as required by Section 3700 of the labor code, for the performance of the work for which this peril is issued. l _ My workers' compensation insurance carder and policy number is: • • • Carrier: STATE FUND Policy number:229-0019928 Expire : 01/01/2005 ea.: •• • • • • (This section need not be completed if the permit 5 for one hundred dollars ($100) or less. •••• •eiv •• •I certifythat in the performance of the work for which this permit is issued, I shall note employ anyperson in anymanner so as to beQrme subject a rke compensation pe do Y I i� D laws of CeMorma, and agree that if I should become subject to the workers' compensation provyrtis of Section 3700 of the labor corlet thaR(onhl4ilh cw'yly with those provisions. 1,tp t- O`'t Applicant Signature : )_.A:,1 n)- Warning: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalUeS end el rhe••plo one hundrsclethousand dollars (5100,000), in addition to the cost of compensalionpanoges as provided for in Section 3706 of the labor code, TItt rtsl,•ndOttrymel%s feel.• •••• • • • •�• • • • • • • • • • • • ••♦ • • • • • • I hereby acknowledge that I have read this application: that the information given is correct; and that 1 am the ownedor duty autfiglized $ fA of the ore. I agree l• comply with atyand state laws ruing construction; and in doing me work authorized thereby, no person will be employed in violation of the labortode Mthe state of California relating to workmen's mpensalion insurance. Permittee Name (Print) ,�,,I to s ✓ATSVYi Address : Signature of permittee: / / __.J_. ttitsr‘ie-• •. • • • ••• •• • r •••y • • tit% •-.1`l• � b`t Approvals Soil Pipe (ground) Sewer Water Pipe (ground) Gas Pipe (ground) Plumbing (rough) Gas Pipe (rough) Water Heater Gas PSI Test Gas Co Notified Final Inspector/Date PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VAID INSPECTION City of Newport Beach Building Department ELECTRIAL Permit No: E2004-0078 PO Box 1768 Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection Requests/Telephone (949)644-3255 Job Address: 1 HOAG DR Bldg: 1 Floor: 1 Suite: Inspector Area: 7 Owner: Address: Code Edit: 2001 Legal Description: HOAG MEMORIAL HOSPITAL ONE HOAG DR NEWPORT BEACH CA 92658 Phone: 949-574-4477 Issued Date: 02I2412004 Processed By: Contractor: Address: Phone: Con State Lic: Lic Expire: Bus Lic: Lic Exp Date: WATSON INV DEVELOP 18182 SERRANO AVE VILLA PARK CA 92867 714-832-1191 436023 03/31/2005 Description of Work: ELEC/TENANT IMPROVEMENT (1ST&3RD FL CONF CTR) B2004-0130 Inspector Notes: cit Y 1 1 r S.t*mewls 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: 62 Fixtures: 24 Sep Circuits: 0 Signs Branch Circuit: Each Add Circuit: Time Clocks: 0 0 0 TOTAL: $107.00 FEES Motors/Transformers (HP/KVA) $45.20 0 to 1 HP/KW/KVA: $22.40 1 to 10 HP/KW/KVA: $0.00 10 to 50 HP/KW/KVA: 50 to 100 HP/KW/KVA: Over 100 HP/KW/KVA: $o.00 $0.00 $0.00 Piggy Back/Temp Power: Temp Power Pole: PAYMENT: $0.00 S0.00 S0.00 $0.00 $0.0o $0.o0 $0.00 $16.90 BALANCE: d/?Vi/u-etp S Temp Underground: Sub Panel: Record Mgmt Fee: Plan Check Fee: Investigation Fee: Issuance Fee: Supplemental Fee: $90.10 a $a.ao 0 $0.00 0 Mao 0 $0.00 $0.50 $16.90 $0.00 $22.00 $0.00 LICENSED CONTRACTORS DECLARATION 1lereby affirm under penalty of perjury that I am licensed under pro and y license is in full force and effect. fi Lice c:436023 Class: •,,,� ons of Chapter 9 (commendng with Section 7000) of Division 3 of the Business and Professions code, Date: 1•i.Y• v%( Contractor: WATSON INV DEVELOP WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perury one of the following declarations: I have and wit maintain a certificate 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 \'shish this permit is issued. �"^^ have and will maintain workers' compensation insurance, as required by Section 3700 of the labor code, for the performance of the work for which this permit is issued. M'j workers' compensation insurance carrier and policy number is: Carrier: STATE FUND Policy number:229-0019928 Expire Date: 01/01/2005 • • • • 041 (This section need not be completed if the permit is for one hundred dollars ($100) or less. • • • • • • • • I certify!bat in the performance of the work for which this permt is issued, 1 shall not employ any person in any manner so as to Stdollle! 1jece to the workers' compensation lawsp/California, and agree that if I should become subject to the workers' compensation provisions ..off �Section 3700 of the labtr/'ytjp, I jhatt rlhwijranplywth those provisions. DSte: �' 2. �.`1 ^ OU Applicant Signature( Warning: Failure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), in addition to the cost of compensalion,damages as provided for in Section 3706 of the labor core, intereSe�id $ittrreyt 7e3ys. : • • : • • • .•• • .w..•.• • •.... •• I hereby acknowledge that I have read this application; that the information given is correct; and that I am thebw•eq er obly.•ufhflrizM a2enl athaow•er. I agree to comply with city and state laws regulating construction; and in doing the work authorized thereby, no person wilds :nipPoyea jntiolaliQn of the Ialar et:l of the s Pe of' • • California relating to workmen's compensation insurance. Permittee Name (Print) / (l\\CAS Va -S Ora Signature of pernittee: Address: • • • • • ••• ••• •• •• • •i,7atc: • i t.'-'- O 1 • •� Approvals Grounding Electrode Underground Under Slab/Floor Rough Conduit Walls Rough Wiring Ceilings Rough Sevice Temp Power Utility Company Notifte Final Inspector/Date PERMITS EXPIRE 180 DAYS AFTER ISSUANCE OR LAST VALID INSPECTION. 1% C [(c; T ; "