101104557 - Permit (2) - Laserfiche WebLink

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BUILDING. INSPECTOR RECORD SITE.WORK DATE !D/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf !oor/Ve nUl ns u latio n Roof Sheathinq V/zz/pr;^UY";A Shear Wall (' / - /u Framinq Insulation/Eneroy Drvwall Ext./lnt. Lath Brown Coat lMasonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif . FINAL Certificate of Occupancy Notes, Remarks, Etc. OWNITR B Lrl Ll)l.lR DI.:LCA RATION I hereby affirnt under penalty of perjury that I anr exempt fnrm the Contract<1ru' License Law for the following reason (Sec.7031.5 Ilusincss and Profcssion Code): Any City or County which rcquircs a Jrcrmit to construct, alter, irnprove, dcrnolish or repair any structure. prior to its issuancc. also requires the applicant ttlr such pcrnrit to fih a signed slaterncnl that hc or she is liccnsed pursuant to the prnvisions of thc Contractor's l,icensed law (Chapter 9, Commencing with Section 7(fi) of l)ivision 3 of the Business and Professions Code) or that he or she is exempl therefrom and the basis lbr the alleged exemption. Any violation of Section 703 I .5 by any applicant for a pennit subjects the applicant to a civilpenaltyof not more than five hundred dollars ($5tXl1. _t. as owner ol'thc propcrty. or my employecs with wages as thcir solc compcnsalion, willdo thc work and the stnrcturc is not interrlctl or offered for sale (Sec.7044, Business and Pmfessions Code: Thc Contractor's Licensc l-aw does nol apply lo an owner of the proJrerty who builds or improves thereor\ and who docs such work himself or herself or ttuough his or her own employees, providcd that such improvements arc not intended or olTercd for sale. Il, however. thc building or irprovenrnt is sold within one ),ear of conrplction, thc Owner Builder will travc thc burden of proving that hc or she did not build or impmve thc propcrty for thc purposc of s:rle). _I. as owner of thc propcrty, am exclusively contracting with licenrcd contractom to conslruct thc projec't (Scc. 7044, Business and hotLssirxr Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contracto(s) licenscd pursuant to thc Contrador's Licensc [aw). _l am excmpt under Section-, B. & P.C. tbr this reason. f 1...,.. woRKhlRs' coNt tr!:NsA't'IO N DECLARATION I hc'rr'by ail'irm undcr pcnalty of pcrjury onc ol'thc tirllowing (lcclarati()ns: _l have ard will maintain a Certificate of Consent to Self-lnsurc for workers' comlrcnsation. as provided for by Scction 3700 of the t abor Codc, for the performancc of the work for which the permit ls lssued. _l have and will maintain workers' conrpensation insurance, as required by Section 3700 of the Labor Code, for the performarrce of the work for which this Jrcrmit is issucd. My workers' compcnsation insurancc carricr and plicy number are: Policy _l ccrrity that in thc Jrcrtbrmance of the work for which this pcrmit is issued, I shall not cmploy any lrcrson in any manner so as to bccomc subject to the workers' compensation laws of California. and agree that if I should beconrc subjcct to thc worhers' c<lnr;xnsation provisions of Section 3700 of the Labor Code, I sJrall, forthwith r,onrply with thorc provisions. WARNING: Failure to sccure workers' cumJrensation covcmgc is unlawful. and shall subject an employer to criminal pcnalties and civil fines up to one hundred thousand dollars ($lm.Uru). in addition to the cost of conrpensation. damages as provided lor thc Section 3076 of the l-abor C<xle, fulterest and attorney's fees. I)ate: I,ICENSED CoNTRA(:TOR DECLARATION I hcrcby alltrm undcr pcnalty of pcrjury that I am licensed undcr provision ol'Chaptcr 9 (cornnrencing with Scction 7000) ol'l)ivision 3 of thc Busincss and Pnrfessions Code. antl my liccnsc is in full fbrce iuxl ctfect. Licensc Class: Licensc Nurnber: Date: CONSTRI.'CTION I,T:NDING AGI.]NCY I hereby all-rrm under Jrnalty of periury that there is a construction lending agerrcy lbr the performance of the work lbr which this permit is issucd (Scc. 3097, Civ. C.). Lcnder's Nanrc: lrndcr's Address: APPLICANT DECLARATION I hercby affrnn under penalty of perjury one of the following declarations: Denxrlition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required lrtter of Notification _l certify that tlrc federal regulations regarding asbeslos renxrval are not applicable to this project. _l certify that I have reatl this application arxl state that thc above information is correct. I agrec to comply with all City and County ordinances and State Laws relating to building constructioru and hereby authorize repre:rcntalives of this City and County to enter upon ttrc abovc mcntioncct proprty lbr inspcction purposcs. Applicant or Agcnt Signolure: Date:- Permitee name (print): 0B-07-2015