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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON <br />I hocby a[firrn under poalty of perjury thal I m exempt from thc ContractoE' License Law for the following .".rnn (S*.zO] I.5 <br />Businas md Profesion Code)r Any City or County which require a pmit to conslruct. alt6. improve. dmolish or repair any. <br />structure. prior to ils issumce. also requirs the applicant for such pmit to file a signed statmot lhd h@r she is licmsed pursuant <br />lo thc ptrovisioN of lhe Contractor's Licensed law (Chaplfi 9. Cornrnencing Nith Section 7000 of Division J of the Busins and <br />Professions Codc) or lhat hc or she is exempt thBcfrom and the b6is for the alleged cxonption. Any violation ofs(tion 70.1 1.5 by any <br />applicantforapcnnilsubjeclsthc applicanttoacivilpcnaltyofnotmorclhanfivehundreddollas($500). <br />l. o orvncr oflhe property. or my employG with wage c their rele composalion. will do the work md the strucl@ is not <br />inloded or offoed for ele (Se.7044. Busines md Prcfsions Code: The Conlractor's l,icrue las dos not apply to an orra of <br />(he prop€fly who boilds or improve th66tr md who do6 such work himself or hmclf or through his or h6 om employce. <br />provided that such improvmots ae nol inladed oroffced for glc. l[ howws, the building or im;rovmot is rcld within one ;a <br />ofcompletion, the Ormq Buildq rvill have the bud6 ofproving that he or she did not build or improve thc prcpsty lor lhe purposeof <br />sale). <br />-1, <br />c owno of the gopoly. m cxclusively contracting u ith licflsed contradoElo construcl the pmjd (Sc. 7044. Busins <br />and ProftsionCode:ThcContractor'sLicenseLawdo6nolapplytoanownsofpropffywhobuildsorimprovesth6@n. <br />and who conlracls for such projets with a Contracto(s) licosed puBumt lo lhe Contractor's Licose Larv). <br />I am exempl unds Section,B. & l'.( . for lhis reason. <br />X" I )'lg .toi:./hq( r qr ,. <br />DECI,ARi\ I'I()N <br />I hereby affirm unrler penalty ofpojury one ofthe follorving declaations: <br />-l <br />have md rvill rnaintain a Cffificale of Consml to Self-lnsure for rvorkm' compmsation. 6 provided for by Sstion 3700 of the <br />hbor Code. for the pcrfommce of the rvork for which the pqrnil is i$ued. <br />Ihaveandrvillmaintainrvorkos'compensationinsurance.N rcquiredbySection.3T00ofthel.aborCode,forlhepsfomanceof <br />thc work for rvhich lhis pemit is issued. My workos' cotnpensattrn insurance canio md Jnlicy nurnber ue: <br />Policy Number lixpires: <br />I certify thal in lhc perforrnance oflhe work for which this pernit is issued. I shall not mploy any psson in any manns <br />so ro to becorne subj*l to the workos' compensalion laws of Califomia. and agre thal if I should becotne subj(l lo lhe <br />rvorkss' cornpensation provisions ofSttion 3700 oflhe tabor Code. I shall. fonhwilh comply with thos provisions. <br />WARNINC: l:ailurc to sure rvorkm'compensation cormge is unlawful. ild shall subj(t m mploy,o to oiminal poaltie and <br />civil finesuploonehundredlhousanddollaB($100.000).inadditionlothecostofcompenstion.damagesasprovidedforthe <br />Section ,1076 of lhe l,abor Code. inlerdl dd atlomw's [6. <br />lld c,Yq <br />DECLARATION <br />I hocby affirrn unda penalty of pqjury thal I m licmsed undo prcvision ofChaptq 9 (commocing with Section 7000) of Division 3 <br />ruf the Busincs md Professions Code, ad my licose is in full force md effst. <br />License Clas:Number: <br />)e,,",a -F -?o/-l lw <br />CONSTRUCTION LENDING AGENCY <br />I hoeby aflirm undr penalty of pqjury that thqe is a comtruaion lcnding agocy for the pofomocc of rhe work for which rhis pqnit is <br />issued (S<. 3097. Civ. C.). <br />Lendq's Namc; <br />l,cnds's Addras: <br />APPLICANT DECLARATION <br />I haeby affirm unds penalty otpojury one of the followinS d(ltrations: <br />I)ernolition Permils-Asbdtos Nolification Fedtral Rcgulations (Title 40. Paa6) <br />R€quired lrltd of Notifi calion <br />_l cftify thal lhe fedgal regulatioE regading 6b6tos rmovAlee not applicable to this prcjet <br />I cenify thal I have read this applicalion ild slalc lhal lhe ab()ve infotrnalion is corrcct. I agrtr to cornply wilh all Cily and (-ounty <br />authorize reprGmtalive of this City md Counly to 616 upon lheordinailcB and Stale l.aws relaling to <br />@ I l\t 00t t if4- <br />i)-/9-20/? <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsu lation <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 (" 'LY 4)(-L t9 N" lO YU-ZD <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />Canis: <br />/,1)r.,( ,^(t