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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DEI,('ARA'TION <br />I hereby affirm undo penalty ot periury that I dn erempl fiom lhe ContracbE- License Law for the follo$.ing redon (Se.70-11.5 <br />Business ard Profssion Code): Any Cily or ('ounty Nhich requirs a pmnil lo conslruct. alt6. improve. denolish or rep.ir any <br />sn'uclurc.priortoits issuance.alsorequirestheapplicantfirrsuchperrnjltofilcasiSnedslatemtrt thathcorsheislicensed pusrant <br />lo lhe pro!isions oflhe Conlrack)r's l.icensed Law (('hapls 9. Conlnencing sith S(tion 7000 ofDivision 3 oflhe Busincss md <br />Pnrfessions ('ode) or lhat he or shc is exempl lhqeliorn and lhe basis for the allegcd eremption. Any violation ofSslion 703 1.5 by any <br />applicant for a pemit subjftls the applicant to a civil pcnalty of not rnore lhan llve hundrcd dollars ($500). <br />, l. as orvncr oflhe propeny. or my etnployees with wagcs 6 thcir sole coillpensation. will do the work md the ilNcture is nol <br />iilmded or oflsed for sle (5(.7044. Busines and Profssions Code: I he Conlractor's l.icms€ l-as do6 not apply to an orvno of <br />thcproFrly rvhobuildsorirnprovatlrq@n.ddwhodo6suchrvolkhirnselforlroselforthreughhisorhdownenlployes. <br />providedth.tsuch irnprovsnmtstrenolintmdedoroffqqlforsale.lf.ho\v$,6,thehrildingorirnprovonenlissoldwilhinone]ru <br />ofcompldio[ lhe (hvner Buildq s ill have lhe burdm ofproving thal he or she did not larild or improle lhe prcpd]., for thc purFrs of <br />sle). <br />l. as owner oflhe propaty. an exclusively conlracling with licmsed conh'actoN lo construct the prej(t (Sec. 7044, Busin6s <br />and ltofession Code: The Contraclor's License [-arv doe not apply to .n orvntr ofpropeny who builds or irnprc,r.es theron. <br />and \\ ho conlracls for such pojets rvith a Conhaclo(s) licensed pursuant to the Codlraclor's Lico$e l-a$'). <br />I iln cxempl under Sslion_ll. & l'.('. lir llris rcason. <br />DSter Owner: _, <br />woRKltRs' cotll PENsA't'to N <br />DECI,ARA I0N <br />I hereby aflirm under penahy of pojury one ofthe follorving declarations: <br />lhaveudu'illnrainlainaCedificaleo[ConsenttoSelf-lilsurcforrvorko's conrgrensalion.o providedforbySstionST00ofthe <br />Latmr (hde. ftrr the po fomance of lhe work for which lhe pmnit is issued. <br />I have and rvill maintain rvorkers' compensation insurancc. m required by Section -1700 oflhe Labor ('ode. for the pqfomance of <br />lhc *ork for \hich this.Imrit is i$ued. My rvorkm' compcnstion insurance caricr ild policy nurnber ae: <br />cania Zrr- a F' r ' <br />,^u*r*,,^ni lZaZa-zrran - Erpres: ,4r-/S'r /- <br />- <br />I certify lhat in lhe performance ofthe work for which this permit is issued. I shall nol employ any penon in any mmr.tr <br />s 6 to beconre subj(l (o lhe wo*6' compsEation larvs of Califomia, and agree that if I should become subjat to the <br />workos' coilrpensalion provisions ofSection -1700 ofthc Lat$r ('ode. I shall. fonh$ilh conply rvith those <br />WARNINCT Failure to sue rvorka's'cornpmsation corcrage is unla*'ful, and subiect an prraltis and <br />civil fincs up lo one hundred thousand dollars ($l in arldition to for lhe <br />Seclion 1076 oI Lalxx iilcresl aild atlomcy s <br />I hocby alfirm undo pmally of pojury that I am licmsed uild6 pr(vision ofChapttr 9 (comnrocing rvith Section 7000) of Division -1 <br />of the Busins and Profssions Code, ad rny license is in full force and effect. <br />t-iccnsc(rass I CIC <br />Da,e to/r{/z <br />/4r?z <br />CONSTRUCTION LENDING AGENCY <br />I hereby aflirn undo penahy ofpsjury lhat lh6e is a construction lmding agcncy for the pofommce ofthe u,ork for u'hich this pennit is <br />issued (Sa. 3097, Civ. C.). <br />Lends's Nanre: <br />I-ender's Addrss: <br />APPLICANl' DECLAIL{TION <br />I hueby alfimr unde poalty of perjury one of the following d(ldalions: <br />Deilrolilion I'crmils-Asb6los Nolillcation Fedsal Regulations ( l itle 40. Parl6) <br />Rcquired Lellcr of Nolilication <br />I cciliry lhal lhc lbds al regulations rcgucling mbtshs ronoval oe not applicable <br />I cdify thal I have reacl this applicalion and <br />ordirrarrcts and Slatc l.au's relating to builclirrg <br />alnvc rnentionccl propeny firr inspetli6ira <br />Al)l)licanl or,\genl Sigilrlurc <br />l'rrilrilR nrtrre (priol):Z <br />hschy <br />lhis <br />lhlr: <br />with all City and Counry <br />md Counly lo ?q utnn lhc44, <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenVl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />FINAL I I ze/rr2o /)Jtfi 'w) <br />Certificate of Occupancy tl <br />Notes, Remarks, Etc.