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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby aflirm undr penalty of pojury tha I an exempt from lhe Contracto6' Licmse Law for the following rron (Sc.7031.5 ' <br />IJusinss md Profsion Codc): Any City or Counly which rcquirc a permil lo construd. all6, improve. dmolish or ,foi, -y' <br />struclure. prior to its isumce, also requirG the applicilt for such pemit to file a signed statemmt that he or she is licmed pmumt <br />ro the provisions of the Contractor's Licenscd Law (Chaptcr 9, Commencing with Section 7000 of Division 3 of the Business md <br />Professrons Codc) or that he or shc is exempl lhacfrom ed lhe b6is for the allcgcd exmplion. Any violation of Sation 70-11.5 by ey <br />applicantforapennitsubjectsthe applicanttoacivilpenaltyofnotmorethmllvehundreddollas($500). <br />l. o orvno oflhe propeny. or my employe with wage 6 lheir ele compensation. will do thc work ild lhc structue is not <br />intmdcd orolTcrcdforelc(SE.T044,BuinosandProlasionsCode:TheContractor'sl.icsseLawdosnotapplytomownoof <br />thepropeny whobuildsorimprovethq@a,mdwhodo6suchworkhimselforherselforthreughhisorhcrownemployes. <br />provided that such improvmols ue not intodql or offqed for sle. If, howryq, the building or im;novcmt is mld whhin onc ,qr <br />ofcornpletiotr lhc Orvns Buildr rvill havc the hrdm ofproving tlm he or she did not build or inrprore the propoty for the purpow of <br />sle). <br />_,1, m ou'nci oflhc propoly. aI cxclusively cofllracting with liccnsed contracloc to construct the prcject (Scc. 7044, Bsines <br />md ProftsionCodc:'IheContractor'sLicenseLawdo6nolapplytodowotrofpropenywhobuildsorirnproveslhtrsn. <br />and u'ho contracts for such projets rvith a Contraclo(s) licosed puGumt lo lhe Contraclor's Licosc [aw). <br />I iln exefipl undq Section-, B. & P.C. for this re6on. <br />Dste:__ <br />WORKERS'COMPENSATION <br />DECLARATION <br />I hcreby affirnr u nder poalty o f ptrjury one of the following declarat ions: <br />__l have md will maintain a Certificate of Cons$t to Self-lnsure for workm' compwlion. s provided for by Setion -1700 of the <br />tabor Code, for the pqfommce of the work for which the psrnit is isued. <br />I have and rvill rnaintain worko's' cornpensation insurance. as requircd by Section -1700 ofthe Labor Code, for the pdfonnance of <br />thc work for which this pfinil is issucd. My workos' compensalion insuruce carier md policy nurnbe ae: <br />('micr: ]: SA"+. ru"d <br />zlt o lt <br />I ceniry thal in the performance ofthe work for which this pomit is issued. I shall not mploy any person in any rnmncr <br />s 6 to become subjet to the work6'compeNlion laws of Califomia. md agrc thd if I slnuld become subjel lg thc <br />s'orkqs' comp€rsarion provisiom ofsection 1700 ofthe tibor Code t shall. fonhwith comply rvith thos provisiim. <br />WARNING: I;ailurc to scure workm' cornpemalion coverage is unlawful, md shall subjet u onployo to aiminal pemltie md <br />civil ftnesuptoonehundredthousanddollm($100,000),inadditiontothecostofcompensalion,danagesoprovidcdforthe <br />DECLARATION <br />I hcrcby affrm und6 psalty of pcrjury that I an licmsed under povision ofchaptq 9 (cornmmcing with Setion 7000) of Division 3 <br />of the Busins md Prcf*ions Code. and my licme is in full force md effet. <br />l.iccosc Nurntrr:?< z gos <br />CONSTRUC'TION LENDING ACENCY <br />I hercby aflirrn under Jrenahy of pertury that thtre is a construction lending agcncy for the pqfonnance oflhe rvork for which this permit is <br />issued (Sec. 3097, Civ. C.). <br />APPLICANT DECLARATION <br />I haci'y afErn undo pmalt y o f perjury one o f thc fo llowing da laat ions; <br />Demolition P6rnils-AsbGtos Notitication Federal Regulations (Title 40, Pan6) <br />Required Ldts of Notificalion <br />__l cfiiry that thc fedoal rcgulatiom reguding rbctos rmoval ae not applicable to this prejd. <br />a--:J cstii, that I have r@d this application md sratc that the above infomation is coret. I agra to comply with all City and County <br />ordinanc6 md Stetc ltws relating to building construction. md hercby aulhotizc rcprsentativ6 ofthis Cilyjmd Counly to stq upon the <br />abovc mentioncd prolrcTty for <br />4pplicsnt or.lgcnt Signature: <br />I'crnrilcc nanrc <br />6 ?r LoZC) <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenVl nsu lation <br />Roof Sheathing <br />Shear Wall <br />Framinq <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 />Enqineer Final Report <br />Flood Zone Certif <br />{f *t*L tztfliw*2--zs -2e ?,_1,to> <br />FINAL 2-?a- ?a A,at ,t t <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />ONner: <br />rhricyNurrrber: - 9Oqggat <br />Detc: <br />lrnds's Name: <br />Lmdq's Addrqs: <br />-