HomeMy WebLinkAboutF2002-0278 - PermitsCity of Newport Beach
Building Department FIREALRM Permit No: F2002-0278
PO Box 1768/3300 Newport Blvd., Newport Beach, Califomia 92658-8915 Permit Counter Telephone (949)644-3288 Inspection RequestsTelephone (949)644-3255
Job Address: 1 HOAG DR Bldg: 1
F%o
Inspector Area/ Legal Desc.:
Owner:
Address:
Phone:
Applicant:
Address:
Phone:
HOAG HOSPITAL
1 HOAG DR
NEWPORT BEACH CA92658
949/574-4477
WATSON INVESTMENT DEV
18182 SERRANO AVE
VILLA PARK CA 92861
714/974-6421
Edit Cade:
Type of Construction:
Occupancy Group:
Added /New sq.ft. Bldg :
Added /New sq. ft. Garage:
No of Stories. :
No of Units :
97
3
Floor:
Suite:
Contractor:
Address:
Phone:
Con. State Lic. :
Lic Expire:
Bus. Lic.:
Lic Exp Date:
R�4
BRIGGS ELECT I /� Architect:
Address:
Phone:
Engineer:
Address:
Phone:
Designer:
Address:
Phone:
Special Conditions:
16662 MILLIKAN AVENUE
IRVINE CA
949-863-9901
297836
08/3112003
BT01013033
12/3112002
Description of Work: FIRE ALARMIFLOOR 1
1790-2002
Workers' Compensation insurance --
Carrier: US FIDELITY & GUARANTY
Policy No:
Expire:
D123W000029
07/01/2003
Issued Date: 08/27/2002
Construction Valuation: $2,666.00
Fire Plan Check Fee :
Fire Permit' Inspection Fee:
Record Management :
Issuance Fee
Investigation Fee:
$106.00
$106.00
$0.50
$0.00
$0.00
State Lic:
State Lic:
FEES
TOTAL FEE : $212.50 TOTAL PAYMENT : $106.00
$0.00
$0.00
TOTAL DUE : $106.50
PROCESSED BY:
ZONING APPROVAL:
FIRE APPROVAL:
OTHER DEPARTMENT:
PLAN CHECK BY:
APPROVAL TO ISSUE:
3av: J 6,2,e.h.a4A,cia
4oRr MUST BE S: A 77— D W,THIN A PERIOD OF i80 DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID.
APPROVALS
DATE
BY
COMMENTS
OWNER -BUILDER DECLARATION
FIRE PROTECTION
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS
LICENSE LAW FOR THE FOLLOWING REASON
UNDERGROUND ROUGH PIPE
(SEC. 7031. 5, BUSINESS AND PROFESSIONS CODE: ANY
CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT. ALTER, IMPROVE, CE0. KISH, OR
THRUST BLOCKS EXCAVATION
REPAIR ANY STRUCTURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH
PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS
UNDERGROUND PIPING FLUSH
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 15 EXEMPT THEREFROM AND THE BASIS
UNDERGROUND HYDRO TEST
FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 7C31.5 BY NW APPLICANT FOR A PERMIT
SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5503).
UNDERGROUND/BACKFLGW APRV.
I, AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE
COMPENSATION, WILL DC THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE
SPRINKLER HYDRO TEST
(SEC 7014. BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY
TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, WHO
SPRINKLER FLOW TEST
AND DOES SUCH WORK
HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH
IMPROVEMENTS ARE NOT INTENDED OR OFFERED
SPRINKLER ROUGH PIPE
FOR SALE IF, HOWEVER, THE BUILDING OR
IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLETION, THE OWNEREOILOER WILL HAVE THE
BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE I
I, 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 GOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR
IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED
PURSUANT TO THE CONTRACTORS LICENSE LAW.).
1 AM EXEMPT UNDER SEC. B 6 P C. FOR THIS REASON
STANDPIPE HYDRO TEST
STANDPIPE FLOW TEST
STANDPIPE ROUGH PIPE
CHEM SYSTEM FUNCTION TEST
CHEM SYSTEM APPROVAL
DATE OWNER
FIRE ALARM SYSTEMLICENSED
CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT AM LICENSED UNDER PROVISIONS OF
CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS
CODE AND MY LICENSE IS IN FULL FORCE AND EFFECT,
LICENSE CLASS/LIC NO
ROUGH WIRING
'�J�'/W
q I
SYSTEM FUNCTION TEST
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+0
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CENTRAL STATION MONITOR
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DATE `O/27/OKI CONTRACTOR
/
EON DEC
WORKERS COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS
FIRE MISC.
Y
TANK REMOVAL
TANK INSTALLATION/TEST
C MPENSATI N, AS PROVIDED FOR BY SECTION 3700 OF THE LABOR CODE FOR THE
PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I NAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REQUIRED BY
TANK PIPING PRESSURE TEST
MEDICAL GAS PIPING TEST
SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH
THIS PERMIT IS ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY
NUMBER ARE.
CARRIER
CROSS CONNECTION TEST
POLICY NUMBER
MISC. INSPECTIONS:
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT IS FOR ONE HUNDRED DOLLARS
(3I00) 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 50 AS TO BECOME SUBJECT TO THE
WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AGR T IF I SHOULD BECOME
SUBJECT TO THE WORKERS COMPENSATION PROVISIONS C710N 3700 E LABOR
''/.A�;L FO qq COMPLYTH THOSE PRO
COD(EEES/+W
DATE.:/\v�� D4 ':: TAPPLMNT•-/
✓✓✓ T—'
WARNING: FAILURE TO SECURE CRE WORE £R['. 1ES AND CRC") COVERAGEUPTO N1UNDRE, ND SHALL
OLLARS R1 EMPLOYER TO lON' 9: H E LDS) (' C CIVIL FINES , C TO DAMAGES
HUNDRED THOUSANDIN
SCOLLARS
SE (7 6OF 0),THE
IN AB ORLON �E I THE LDS) AND ATTUK IEYS ON, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE, INTEgE5I, PND ATTUHNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING
AGENCY FOR THE PERFORMANCE OF 'Stic WORK 1 OR N IRA THIS PERMIT IS ISSUED (SEC3097,
CN.C)
LENDER'S W'IE
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION 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
COUNTY UPRN T'IE ABOVE- Nfl'INEI) IMSPER/ Y AR INSPECTION PURPOSES.
//%/�
FINAL
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FIDNATIIRF OF PF F V DATE
City of Newport Beach
Building Department FIREALRM Permit No: F2002-0279
PO Box 1768/3300 Newport Blvd., Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection RequestsTelephone (949)644-3255
Job Address: 1 HOAG DR Bldg: 1
Inspector Area15 ' Legal Desc.:
Owner:
Address:
Phone:
Applicant:
Address:
Phone:
HOAG HOSPITAL
1 HOAG DR
NEWPORT BEACH CA92658
949/574-4477
WATSON INVESTMENT DEV
18182 SERRANO AVE
VILLA PARK CA 92861
714/974-6421
Edit Code:
Type of Construction:
Occupancy Group:
Added /New sq.ft. Bldg :
Added /New sq ft. Garage:
No of Stories..
No of Units :
97
3
Floor:
Suite: Description of Work: FIRE ALARM/FLOOR 2
1790-2002
Contractor:
Address:
Phone:
Con. State Lic.
Lic Expire:
Bus. Lic.:
Lic Exp Date:
BRIGGS ELECT
16662 MILLIKAN AVENUE
IRVINE CA
949-863-9901
297836
08/31/2003
BT01013033
12/31/2002
Workers' Compensation Insurance - -
Carrier: US FIDELITY & GUARANTY
Policy No: D123W000029
Expire: 07/01/2003
Issued Date: 08/27/2002
FEES
Construction Valuation: $2,666.00
Fire Plan Check Fee :
Fire Permit/ Inspection Fee.
Record Management:
Issuance Fee :
Investigation Fee:
$106.00
$106.00
$0.50
$0.00
$0.00
Architect:
Address:
Phone:
Engineer
Address:
Phone:
Designer
Address:
Phone:
Special Conditions:
State Lic:
State Lic:
$0.00
$0.00
TOTAL FEE : $212.50 TOTAL PAYMENT : $106.00 TOTAL DUE : $106.50
PROCESSED BY:
ZONING APPROVAL:
FIRE APPROVAL:
OTHER DEPARTMENT:
PLAN CHECK BY:
APPROVAL TO ISSUE:
wav6 ue t 4,
WORK ,BUST 6F STAR "EN WITHIN A PERIOD OF 180 DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID.
APPROVALS
DATE
BY
COMMENTS
OWNER -BUILDER DECLARATION
FIRE PROTECTION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS
UNDERGROUND ROUGH PIPE
LICENSE LAW FOR THE FOLLOWING REASON (SEC 70315, BUSINESS AND PROFESSIONS CODE. ANY
CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT ALTER, IMPROVE, DEMOL'9H, OR
THRUST BLOCKS EXCAVATION
REPAIR ANY STRUCTURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH
PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS
UNDERGROUND PIPING FLUSH
OF THE CONTRACTORS LICENSE LAW (CHAPTER G (COMMENCING WITH SEC 7000) OF DIV 3 OF THE
BUSINESS AND PROFESSIONS CODE)) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS
UNDERGROUND HYDRO TEST
FOR THE ALLEGED EXEMPTION ANY VIOLATION OF SEC 70315 BY ANY APPLICANT FOR A PERMIT
SUBJECTS THE APPLICANT TO A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS
UNDERGROUND/BACKFLOW APRV.
(55D3)
I, AS OWNER OF THE PROPERTY, OR MY EMPLOYEES WITH WAGES AS THEIR SOLE
COMPENSATION, WILL DO THE
SPRINKLER HYDRO TEST
WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE
(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY
TO AN OWNER
SPRINKLER FLOW TEST
OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK
HIMSELF OR HERSELF OR THROUGH HIS OR HER ONM EMPLOYEE$, PROVIDED THAT SUCH
SPRINKLER ROUGH PIPE
IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE BUILDING OR
IMPROVEMENT IS SOLO WITHIN ONE YEAR OF COMPLETION. THE OWNER BUILDER WILL HAVE THE
BURDEN
' STANDPIPE HYDRO TEST
OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE )
I, AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED
STANDPIPE FLOW TEST
CONTRACTORS TO CONSTRUCT THE PROJECT (SEC 704A BUSINESS AND PROFESSIONS CODE THE
CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR
STANDPIPE ROUGH PIPE
IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(5) LICENSED
PURSUANT TO THE CONTRACTORS LICENSE LAW
CHEM SYSTEM FUNCTION TEST
IAM EXEMPT UNDER SEC B&PC FOR THIS REASON
CHEM SYSTEM APPROVAL
DATE OWNER
FIRE ALARM SYSTEJN
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 BUSINESS AND PROFESSIONS
COOS, AND MY LICENSE IS IN FULL FORCE AND EFFECT
ucENSE�c({ASs� LIC NO /
ROUGH WIRING
B/'LQ/F-
SYSTEM FUNCTION TEST
�
C1cr
�'4----
CENTRAL STATION MONITOR
DATE/ / /O7 CONTRACTOR s�.10: :
WORKERS' COMPENSATION DECLARATION /
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWNG DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
FIRE MISC.
TANK REMOVAL
TANK INSTALLATION/TEST
C MPENSATI N AS PROVIDED FOR BY SECTION 3700 OF THE LABOR Tong, FOR THE
PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REQUIRED BY
TANK PIPING PRESSURE TEST
MEDICAL GAS PIPING TEST
SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH
THIS PERMIT IS I55UED, MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY
NUMBER ARE:
CARRIER
CROSS CONNECTION TEST
MISC. INSPECTIONS:
POUCY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT 15 FOR ONE HUNDRED DOLLARS
(E100) OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS COMPENSATION LAWS OF CALIFORNIA. AND AGR E THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS COMPENSATION PROVISION SECTION 3700 THE LABOR
ODE,HWI
�E� ALL ORTHTH COMPLY WITH THOSE NS
DATE -2I - - AUPUCANi
WARNING F LURE TO SECURE WORK.RS' LOMPENSA. N COVERAG UNLAWFUL D SHALL
SUBJECT AN EMPLOYER TO PRIMINAL PENA41 .ES AND CWIL FINES UP ONE HUNDRED THOUSAND
DOLLARS (E100000), IN ADDITION, Tr TV) COPT OF FOMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 370E OF THE LABOR CODE INTEREST, AND ATTORNEY'S FEES
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE 15 A CONSTRUCTION LENDING
AGENCY FOR THE PE4F04MAHCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC 3097,
CIVC)'
LENDER'S 4*15
LENDERS ADDRESS
1 CERTIFY THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS
CORRECT I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS
RELATING TO BUILDI"C CCN^TRUCTVIH AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS
COUNTY LTD(-THEABOVE'X 10"ED PRC'ERTY FIR INSPECTOR PURPOSES
FINAL
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City of Newport Beach
Building Department FIREALRM Permit No: F2002-0280
PO Box 1768/3300 Newport Blvd., Newport Beach, California 92658-8915 Permit Counter Telephone (949)644-3288 Inspection RequestsTelephone (949)644-3255
Job Address: HO4AttG DR Bldg: 1
Inspector Are Legal Desc.:
Owner:
Address:
Phone:
Applicant:
Address:
Phone:
HOAG HOSPITAL
1 HOAG DR
NEWPORT BEACH CA 92658
949/574-4477
WATSON INVESTMENT DEV
18182 SERRANO AVE
VILLA PARK CA 92861
714/974.6421
Edit Code:
Type of Construction:
Occupancy Group:
Added /New sq.ft. Bldg :
Added /New sq. ft. Garage:
No of Stories. :
No of Units :
97
3
Floor:
Suite:
Contractor:
Address:
Phone:
Con. State Lic
Lic Expire:
Bus. Lic.:
Lic Exp Date:
BRIGGS ELECT
16662 MILLIKAN AVENUE
IRVINE CA
949-863-9901
297836
08/31/2003
8T01013033
12/31/2002
Description of Work: FIRE ALARM/FLOOR 3
1790-2002 -
Workers' Compensation Insurance - -
Carrier: US FIDELITY & GUARANTY
Policy No: D123W000029
Expire: 07/01/2003
Issued Date: 08/27/2002
Construction Valuation: $2,666.00
Fire Plan Check Fee :
Fire Permit/ Inspection Fee:
Record Management:
Issuance Fee :
Investigation Fee:
$106.00
$106.00
$22.00
$0.00
$0.00
r
FEES
Architect:
Address:
Phone:
Engineer:
Address:
Phone:
Designer:
Address:
Phone:
Special Conditions:
State Lic:
State Lic:
$0.00
$0.00
TOTAL FEE : $234.00 TOTAL PAYMENT : $0.00 TOTAL DUE : $234.00
PROCESSED BY:
ZONING APPROVAL: • • • • •''
• r • •
11•
• . •. •
FIRE APPROVAL:
•
OTHER DEPARTMENT:
PLAN CHECK BY:
APPROVAL TO ISSUE:
Oa vrcI 6-?cv)e-ce c,,_
Do -
RIB eWtRK MOST BFL5'SJA'771V'U I0tITHIN A PERIOD OF 180 DAYS FROM THE DATE OF VALIDATION OR THIS PERMIT BECOMES NULL AND VOID.
• , 1 • , e
. 0 •
•
I
1 1 1
1•
Iu
•
APPROVALS
DATE
BY
COMMENTS
OWNER -BUILDER DECLARATION •
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM TLIE CONTRACTORS
LICENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5, BUSINESS AND PROFESSIORS CODE ANY
IMPROVE. DEMO(tA, OR
FIRE PROTECTION A
� �
/ZAA- 9t- En- %0 .' MIA"-
UNDERGROUND ROUGH PIPE
CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT, ALTER.
REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE. ALSO REQUIRES THE APPLICANT FOR SUCH
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 SECT000) OF DIV 3 OF THE
BUSINESS AND PROFESSIONS CODE)) OR THAT HE OR SHE IS EXEMPT THEREFROM ANO THE BASIS
FOR THE ALLEGED EXEMPTION. ANY VIOLATION OF SEC. 7031.5 BY ANY APPLICANT FOR A FERMIT
SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (S5031
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. 7044, 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 15 SOLO 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 SALE.(.
I, 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 GOES NOT APPLY TO AN OWNER OF THE PROPERTY WHO BUILDS OR
IMPROVES THEREON, ANO WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S) LICENSED
PURSUANT TO THE CONTRACTORS LICENSE uw).
I AM EXEMPT UNDER SEC. BSP.0 FOR THIS REASON
THRUST BLOCKS EXCAVATION
UNDERGROUND PIPING FLUSH
UNDERGROUND HYDRO TEST
UNDERGROUND/BACKFLOW APRV,
SPRINKLER HYDRO TEST
SPRINKLER FLOW TEST
SPRINKLER ROUGH PIPE
STANDPIPE HYDRO TEST
STANDPIPE FLOW TEST
STANDPIPE ROUGH PIPE
CHEM SYSTEM FUNCTION TEST
CHEM SYSTEM APPROVAL
DATE OWNER
FIRE ALARM SYSTEM
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I PM LICENSED UNDER PROVISIONS OF
CHAPTER 9 (COMMENCING WITH SECTION ]COD) OF OIVISION 3 OF THE BUSINESS AND PROFESSIONS
CODE. AND (COMMENCINGOF .
FULLRCE AND EFFECT.
LICENSE CLASS LID. MJ.
ROUGH WIRING
A/�
JJJ���
/ `
SYSTEMFUNCTION
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\\\
STATION MOST
CENTRAL STATION MONITOR
rJ �5
g/t7/02_ CONTRACTOR
DATE
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS -
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.
I HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE, AS REQUIRED BY
3700 OF THE LABOR CCOE FOR THE PERFORMANCE OF THE WORK FOR WHICH
FIRE MISC.
TANK REMOVAL
TANK
TANK INSTALLATION/TEST
TANK PIPING PRESSURE TEST
MEDICAL GAS PIPING TEST
SECTION
THIS PERMIT IS ISSUED, MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY
NUMBER ARE
CROSS CONNECTION TEST
CARRIER
MISC. INSPECTIONS:
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED IF THE PERMIT 15 FOR ONE HUNDRED DOLLARS
ICER OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT K ISSUED,
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 JS TO BECOME tl W RCT TO THE
N/� (�/�/ (i ' L //'S/
�IA�M/li�'�' HA1,[liR(l,
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WORKERS' COMPENSATION LAWS OF CALIFORNIA, AND AG EE THAT IF I S D BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIO F SECTION 37 HE LABOR
yy// CODE, 11 L/L F/QTIWITH COMPLY WITH THOSE PR S.
DATE )C D/ LI/ 02. .• •:AFIUCAt
yaw-) - OH a- k 1ark 4-0a
C*VERAG UNLAWFUL, SHALL
E('I �1
- Di Litt Q �
WARNING. FAILURE TO ECURE W(AIKEYER TO •Ry,`GIMPENCATION
SUBJECT AN
ON, DAMAGES S UP T ONE AS PROVIDED FONDRED R IN
1�
DOLLARS (1103.0001. IN AOOITION TO TS rASjOFFC�MPEIoSIlVL
SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES.
CONR NITY STTRUCTTION LENDING AGENCY LENDING
THAT IS A NS
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2.161 T 1,`YVL-/T�S1
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N i�� OIL. VI I t F'L
EtIIS PiAIAjTRE
AGENCY FOR THE PI RFQRMWJCj CJF♦THE RK FOR Niel.JURY
RSUEDN(SEC 3067,,
o k) ' L S P rcT.
OVCJ . • . .
•
1�r1Ly ��� S I a
A
LENDER'S NAME •
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• ♦ • • • • ♦ •
` Jry�
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• •
LENDERS ADDRESS
IS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION
CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS
RELATING TO BUILDING COY IR tjN, (943•HEREER' GT H; REPRESENTATIVES OF THIS
INS¢¢ECTION PURPOSES.
COUR NTER UPON VIE DNTMINEFIPRpPERTY(IOR
F • • • I
• • •
• •
FINAL
MI E I K • • • • • • -�
37 a2
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