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BU!LDING. INSPECTOR RECORD <br />SITE.WORK COMMENTS OWNER BUILDER DELCARATION <br />! hcrcl'y aiiirnr urrdcr pmaity of pojury thar I m exempt from th€ Conlractom' Liccnse Lav fo, the lbllowing rwrn (Sa.7031.5 <br />Rusinss mci Profsion Codc) Any City or County which requirs a gmnir to coElrud. alto. irnprove. dmolish or repair oy <br />structue. prior to its i$umce. also requirB the applicel for such pemit to file a signcd $lalm6t that he or shc is licmsed pusumt <br />ro thc Frov6ions rrfthc Contractor's Licenscd [-aw (Chaptcr 9, Commencing with Section 7000 ofDivision 3 oflhe Business and <br />ProiissionsCode)orthatheorsheisexemptthqefromodthcb6isfortheallcgcdexonption. AnyviolationofStrtionT0Sl.5byily <br />applicantforapcmitsubj(tsthe applicanttoaciviloenaltyofnotmorethmfivehundreddollrs($500). <br />l, c oMr of Ihc fropcrty. or my employ6 wrth wag6 6 their sole compensation. will do the work od the structue is not <br />rntmded oroilcredforsale(56.T044.BusinessandProGssionsCodc:TheContractor'sLicmseLawdoesnotapplytomownsof <br />thc prepen) who hrilds or improvs thson. md who do6 such wo* himself or herselfor through his or her own employes. <br />pr(rvided that such improvmmts ue not intmdql or olTsed for sle. l[ how*o. the building or improvqnmt is sH within one ]q <br />ofcomplaion. the Owns Builde will have the burdm of[roving lhd he or she did not build or irnprove the prcpqty for the purporeof <br />mle). <br />-_1. re owro ollhe prcprty. en exclusive ly conlracling wilh licqsed conlracloE to co6lruct the project (Scc- 7M4. Buinqs <br />od ProfssonCodc:TheConlraclor'sLicense[.awdo6notapplytodowncrofprop€flywhobuildsorirnprovesthdfr)n. <br />and rvho conlrads for such frojels Nith a Contracto(s) licmscd pursuml lo the Contrador's Licme Larv). <br />I iln exernpt uf,dcr Section--. B. & P.C. for this remon. <br />Date:_.-_ Owner:_ <br />NORKERS' CO[IPENSA'IION <br />DECLARATION <br />I hercby aflirm under penalty ofpujury one ofthe f<rllowing dclarations: <br />_-,lhavemCwillrnaintainaCertificaleofcoNotloSelf-lnsurelbrworkgs compmsation,6 lrovidedforbySetion3T00ofthe <br />tabor Codc for the pefomrmce of the work for which the funil is isued. <br />havc and will rnaintain workers compensation insurance. I rcquired by Sation -3700 of the Labor Code, for the pqfonnoce of <br />thc work for which this pmit is ssued. Mv workss' compensalion insurance carie dd polic! f,umbq ue: <br />,^,,* 7-z/ t&/ <i ?Lea-f- CsqdZ- aF,4 *tatrc-A':":,:;:^m:-Y,^k:^'::k# <br />m mtobcorncsubjattothcs'ork6'compeEationlawsofCalifomiamdagrethatiflshouldbecomesubjGttothe <br />rvorkos' compmation provisioro ol Section 1700 of the tabor Code. I shall. forthwith comply lvith thos provisiom. <br />WARNING: Irailure lo wurc workers'compmation covtrage is unlarvful. md shall subjat an qnployq to oiminal poaltia ad <br />civil fines up lo onc hundrcd thousand dollars ($100.000). in k)providcd for the <br />S(lion -1076 intcrBt and attomey's fes. <br />I)lle: <br />I hoebyaffirrnundopmaltyof psjurythat I an <br />of the Busins and Profsions Code. md my I <br />provision of Chapte 9 (commocing wilh Sstion 7000) of Division 3 <br />force md eff(l. <br />[.iccnsc <br />I hcrcby affirrn under penally ofpcdury thal lhere is a <br />issued (S(. 3097 Civ. C'.). <br />Lender's Narnc: <br />lending agcncy for thc polonnance ofthc wtnk lor which lhis pflnit is <br />l.cnds s ,\ddrcss: <br />APPLICANT DECLARATION <br />I horby affimr u nde pmalt y o f pcrjury one o f thc fo llorv ing dcc laat ions: <br />Dcmolition Pfrmits-Asbstos Notification Fedqal Regulations ('fitle 40, Pan6) <br />Rcquired Letlq of Notificalion <br />_l cdify thar the fedsal regulations regrding obetos renoval ue nol applicable to this proj(t. <br />4 cfiify lhat I have read this application md state that the atDve infomdion is corect. I with all City and (i)unty <br />ordinirncG ald Slalc l-aws rclaling to ulNn the <br />ah)!c nrentioncd propeny for inspeclion <br />Appli(nilt or Agcnt <br />Pcrnrilee nanrt <br />ard <br />l)nte <br />anrl to <br />'zd <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenVl nsulation <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 />Engineer Final Report <br />Flood Zone Certif <br />FINAL Z.?g-l.ol,o Jlrtdtr 7y <br />Gertif icate of Occupancy <br />Notes, Remarks, Etc. <br />DATE i lOtSrC. <br />l).lr