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BUILDING- INSPECTOR RECORD a <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDDR DELCARATION <br />I hacby affum undq pcoalty of pcrjury that t m exmpt fiom lhc Contrrcton' Licw taw for thc following ren (54.7031.5 <br />Busincs ud Profeion Codc): Atry City or County which rcquirc a pornit to @Gtruct. altq, imprcvq ddnolish or r@ir sy <br />structuq prior to its isruacc, also rcquira thc applicilt for such pcrmh to filc a signcd statomt that hc or shc b licms€d p|Nmt <br />to thc plovisio$ of thc Contrator's Licoscd Law (Chapt6 9, Commcing with Sction 7000 of Division 3 of thc Buincs md <br />Prcfcsioro Codc) or that h€ or shc is crmpt thqcfrom ud thc basis for thc alleged cxmption. Any violation of Sctbn 7031.5 by ey <br />applicant for a pcmil subjcts thc applicant to 8 civil p@alty of nol morc tha fivc hundrcd dollffi ($500). <br />_-1. s oM6 of thc lropary. or my cmploye with wag6 6 thsir sle compcnsation. will do the wo* iltd thc $nrdrc b mt <br />intqrdod or otfqcd for slc (Sc.7044, Buine ud Profsiore Codc: Thc Codmclor'3 Licsc lrw do6 not spply lo o oMq of <br />thcpmpqty whobuildsorimprov6th@&edwhodo6suchwrthimsclforhwlforthrcughhisorhdomcmploye <br />prcvidcd rhat such imFomts rc mt intqdod or ofrqcd for sh. lf. howq. th€ building or imFovqrcnt is mH whhin onc )qr <br />ofcompleion. thc Ovmq Buildq will harc thc h[dor ofpoving tha hc or shc did not hrild or imprcw thc prcpaty for thc purpos of <br />ele). <br />_1, 6 omq of rhc prcpqty. m cxclNivcly contracting with licolcd cootractoE to coGtruct ihc projer (36. 7044, Buitrs <br />ard Proftssion Codc: Thc ContBctor's License Law dos not apply to fl own6 ofprcp€rty who builds or imprcvB th66n, <br />od who contrac{s for such prcj61s with I Contrclo(s) licqEcd puEuilrt to the Contrctor's Licffi Law). <br />__l am B. & P.C. for this reason. <br />t <br />I hereby affirm under penalty of perjury one of the <br />_l have and will maintain a Certificatc of Consent to Self-lnsure for workers' comp€nsation. as provided for by Section 3700 of the <br />L^abor Code. for the pcrformance of the work for which the perrnit is issued. <br />__l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrformance of <br />the work for which this permit is issuod. My workcrs' compensation insurance carrier and policy numhr are: <br />Policy Number:- Expires: <br />_l cerri$l that in the performance of thc work for which this permit is issucd. I shall not employ any person in any manner <br />so ils to become subject to the workers'compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the l-abor Code, I shall. forthrvilh cotnply with thosc provisions. <br />WARNING: Failurc to secure workers' compensation coverage is unlawful. and shall subject an onployer to criminal penahies and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation. damages as provided for the <br />Sectron 3076 of interest and <br />I hercby affinn pcnaltyof pcrjury that I an licensed provision of Chapter 9 <br />force and effect. <br />with Section 7000) of Division 3 <br />of the Busincss and Professions Code. and my license is in <br />Licerse Class: <br />-License <br />Numbcr: <br />f)q I r''Contractor: <br />W <br />I hrcby alfim undo pcnalty of pqjury th8t thqc is a onstructbn lcoditrg 8g@cy for thc pqfomacc of thc work for which this pqrnit b <br />issued (Se. 3097, Civ. C.). <br />knder's Address: <br />APPLICANT DECLARATION <br />I hereby affinn under penalty of pojury one of the following declarations: <br />Demolition Pcrmits-Asbestos Notification Federal Regulations (Title 40. Par16) <br />_Required Letter of Notification <br />.__l certi$ that the federal regulations regarding asbestos removal are not applicable to this project. <br />above rnentioncd property for <br />Applicant or Agent <br />I'ermitce name <br />purposes. <br />O <br />t <br />/ct <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/Ve nUl ns u latio n <br />Roof Sheathinq <br />Shear Wall <br />Framincr <br />Insulation/Enerqy <br />Drrnrval! <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 />I -a ,^, <br />F!NAL ///7 ltrfl -,-/wt/ <br />Certificate of Occupancy / <br />Notes, Remarks, Etc. <br />a <br />Carier:- <br />and state that