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BUILDI}IG- INSPECTOR RECORD L <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby aflirrn unda penalty of psjury that I m exempt from lhe ContracloB' License Larv for the folkrrving remn (Se.703 1.5 <br />Busin6s and l'rofsion Code): Any City or County which requira a pennit lo construcl. alto, improvc, dqnolish or repair any <br />slruclurc. prior lo its isuarce. also require the applicant for such pmil to file a signed statmmt thar he or shc is licflsed pursuol <br />to the provisions ofthe Conlraclor's Licensed Law (Chapltr 9. Commencing wilh Section 7000 of Division J ofthe Business and <br />ProfcssionsCode)orthalhcorsheisexempllhqeliommdlheb6isfortheallegcdcxonplion. AnyviolationofsslionT0ll.5byany <br />applicantforaponitsubjatsthc applicanttoacivilpenaltyofnotmorethanfir'chundreddollus($500). <br />_ l. o orvno of the Sroperty. or my cmploye rvith *age m theL mle compemation. uill do lhe wo& md the slrudue is not <br />inlmdql or offoed for ele (Se.7044, Busins md hofsioro Code: The Contraclor's Licos Law do6 not apply lo il ou'nq of <br />lhc protrly who builds or improve th@n. ed who do6 such wo* himself or hmelf or through his or hs own employes. <br />provided thal such im5rovanols ae not intqded orofked for sle. li hows6. the building or improvonenl is sld vilhin one y@ <br />ofcompldion. lhe O\r'no Builds will have the brrdo ofproving thd he or she did nol build or improvc the propqty for the purpos of <br />sle). <br />l. 6 olvner of the properly. m erclusively contracting with licmed contractoElo conslrucl the prejet (Ss. 7(},14. B$ins <br />and FloftssionCodc:TheContraclor'sl,icenseLawdo6notapplytodowntrofpropenyrvhobuildsorimprovesthcron. <br />and rvho conlracls for such projecs rvilh a Contracto(s) licfised pursuot to the Contraclor's LiceNe Law). <br />F4U"1it -| ---@ <br />I hcrcby alfirnr undcr penally oIpojury one ofthe follorving declarations: <br />I have od will nlainlain a Ce[ificale ofConsent to Self-lnsure for work6s' compensalion. a providcd fot by Scctbn ]700 oflhe <br />t-abor Code. for the pofomrance ofthe work for which the pmnit is issued. <br />I have and rvill rnaintain rvorkere' compemation insurance. 6 required by Setion 3700 oflhe Labor Codc. [or lhc psfonnance of <br />lhe rvork for rvhich this ponit is issued. My workffi compffialion insurilce cmie md policy nunrber ac: <br />policyNunrber: -Ir-ooot5Zo?t t"I E-ei,*, ltfl l11 <br />I ceniry thal in the psfonnance of the rvork for u,hich this pmil is issued. I shall not mploy any person in any mmno <br />m otobocornesubirttolhework6'compenxtionlarvsofCalifomia,andagrcthatiflshouldbe.omesubj(ltolhe <br />work6'cornpcnsalionprovisionsofSelionlT00ofthetaborCode.lshall.fonhu'ithcomplywilhthosprovisions. <br />WARNINGT Failure to sue workss'compfi$tion covmge is unlarvful. dd shall subj€t m mployo to siminal penalie md <br />civil fins up lo one hundred thousnd dollm (SI00.000). in addition lo the cost ofcompcMtion. damages as providcd for the <br />S(tion -1076 of thc tabor Code. int6d ed attomey's fc. <br />I hoeby atlirrn undr pmaly of psjury lhal I an licosed unde provision of Chaplq 9 (commocing rvith Swtion 7000) of Division l <br />oI thc l]usinss md Profsiom Code. md my licrue is in full force ild eff6t. <br />Liccnse ('lass:b LicenseNumt*r: :lLn3Z <br />o^", 1lz6l11 <br />CONS'IRUCTTON LENDING ACENCY <br />I hereby aflirm under penalty of perjury lhat thse is a conslruclion lending agency for the pofonnace ofthc u,ork for which this permil is <br />issucd (Sec. .1097. Civ. C.). <br />Lender's Narnc: <br />[,ender's Addrss: <br />APPLICANT DECLARATION <br />I lptb allinn unds penalty ofpsjury one ofthe following delarations: <br />Demolition Ptrmils-Asb6tos Norification Fedsal Regulations (Tille 40. Pdt6) <br />Required Ldl6 of Nolifi cation <br />-l <br />cdify lhat lhc fcdtral regulations regdding abatos rmoval oe not applicable to this prcjd. <br />-l <br />cdify that I havc red this application md state that (he above infomation is cotret. I agrc lo comply with all City and County <br />ordinancG md Stalc Laws rclating to building conslructior\ ild hseby au(horize represtativ6 of rhis City ild County to mtq upon the <br />above motioned prop€rty for iNpection purpos6. <br />y'pplicrnt or ngcnt <br />Yernritce nrnre lprint;: <br />l)alc:lzbln <br />Set Backs <br />Forms/Steel/Holdowns f?z-rQ tt?.<-z| <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenVl nsu lation <br />Roof Sheathing n at -lq /) -a*P,*'LU <br />Shear Wall I u-t ,l./eu//\4.AD <* Nbu y <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath /D-/7-t 9 fta2a <br />Brown Coat i/-v-/?/-cz\ <br />lt/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL 624-zs /L Q,st )xrbs Hry <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />,-?nJ <br />a <br />L <br />a <br />t <br />--. <br />tK,., I lz ul t1 <br />,