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N SPECTOR RECORD \ <br />APPROVALS DATE ID/SIG.COMMENTS Owncr- Builder Dccllretion <br />I lrcreby affirm undo penalty of perjury that I 6m exempt form the Conlrsctors' Liccnse Law for thc following reson (se.703 1.5 Businss <br />and Prcf6sion Codc): Any City or County which rcquira a pcrmit to coNtruct. allcr. imprevc. dcmolish or rcpair any structu.. prior to its <br />issuancc,alsorcquircthcrpplicantforsuchpcmitto,ilcssigncdstatcmcnt thathcorshcisliccn*d puBuanttothcppvisioreofthc <br />Contmclor's Licensed Law (Ch.ptd 9, Commcncing with Scction 7000 ofDivision 3 ofthe Busines and Profasions Codc) o, thrt hc or <br />shc is cxcmpt thcrcfrom and thc b6is for thc allcgcd cxcmption .Any violation ofsetion 703 1.5 by any applicsnt for r pcnnit subjccts thc <br />spplicsnt lo a civil pcnolty ofnot morc thatr livc hundrcd dollas ($500). <br />_1. as owncr of thc prepcny. or my cmployccs with wag6 f,s thcir solc compcnstion. will do thc work and thc structuc is not intcndcd <br />or ofT..cd for slc ( Se 7044. Busin6s and Profcssions Codc Thc Contraclo.'s Licensc Law doe not apply to .n owner of thc p.opsly <br />who builds or improvG thscon. and who do6 such sork hirelf or hmclf or through his or hcr own cmployG. providcd that such <br />improvemcnts irc not intcndcd or offcrcd for salc. If. howcvcr. thc building or imprcvcmcnt is sold within onc ycar ofcomplaion. thc <br />Owncr-Buildff will havc thc burdcn ofproving that hc or shc not build or improvc for the purposc ofsslc). <br />_1. as owner of the propefiy. am exclusively contracting with licensed contractors to construct the project ( Sec. 7044, Business and <br />Profession Code: The Contractor's License [.aw does not apply lo 8n owner of property who builds or improves thereon . and who <br />contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License lxw ) <br />I nrn exernpt under Section __.8. & P.C. for this rcason. <br />Date:Owner: <br />WORKERS COMPENSATION DECLARATION <br />I herehy affirnr under pcnalty of perjury ()ne of the following declarations: <br />_l havc and will rnaintrin a Ccnificrtc of Conscnt to Sclf.lGure for workerr' compcnsation. as provided for by S@tion 3700 of thc <br />lrbor Codc. for thc pcrfomancc of thc wort for which thc p€rmit is issucd. <br />thauc and *ill maint.in workers' compcn$lion insurrncc, rs rcquircd by Sccton 37OO of lhc tihor Codq for th. pcrfo.Jc of thc <br />work for which this pl1mit is issucd My workffi' compcnstion insu.ane carrio and policy numbcr arc: <br />.""n.6c.,{.t Ca,.rrF hl50 <br />-,.r*, <br />(This scction nccd not bc complctcd ifthc psmit is for (hc hundrcd dollaB l$100) or lc$) <br />_l ccrtify that in thc pcrfomancc of thc work for which this pmit is issucd. I shall oot mploy any pcmn in any manncr so s to <br />becanre suhject to the workers' compensation laws of California, and agree that if I beconre subject to the workers' <br />those provisions..compensation provisions of Section 1700 of the Iabor Code. I <br />Dale:lD'16 't5 Applicant <br />WARNING: F.ilure to s6ure workerc'conrpensation coveragc is unlawful, and shall subjst sn cnrploycr to aiminal pcnaltics and civil <br />fin6 up lo onc hundrcd lhousand dollars ($l 00.000).io addition to thc cost ofcompcnsalion. drnugcs r providcd for thc Scction 3076 of <br />thc t-bor Codc. intcrcst and .ttorney's f.cs. <br />LICENSED CONTRACTORS DECLARATION <br />I hcrcby affinn undcr pcnally ofperjury thal I am liccnscd und6 prcvision ofchaplcr 9 (commcncing with Scction ?000) ofDivision I of <br />thc Busincss and Profcssions Codc. and my liccnrc is in full forcc and effccl. <br />r.iccrrsc crn.., -clo + C;Ll5 <br />r)arc: )0.\6. \S <br />frwe[.icense <br />CONS'I'RII("I]ON LENDINC ACENCY <br />I hcrcby aflirrn under pcnalty ofperjuty lhal therc is a constNclion lendirg agcncy for the pqfonnancc oflhc sork for which this pcrnrit is <br />issucd (Sec. 1097. ('iv. C.). <br />l.endcr's Nanre' <br />[.ender's Address <br />API!!(JNB'IECIIAEAIIAN <br />Dcmolition Pmis-A3bcatos Notification Fcdssl Rcguhtion! (Titlc 40. Pln 6) <br />__ Rcquircd lrrtr of Notificdiotr <br />_l ccnify that thc fcdorl rcgulrtions rcgarding Gb6tos moval rrc not lppliclblc to lhfu prejct, <br />l==t!rti& thar I havc rcrd this applicstion 8nd stEtc that thc rbovc infomrtion i! coct. I Egrc to comply uith all City and County <br />'ordinlncB rnd Strtc Lrvt rclrting to building comtruction, and hcrcby authorirc rcprBcotstivG ofthis City snd County to qtcr upon thc <br />above nrentioned property for <br />Applicant or agent sig.: <br />Perrnittee narne (print):f= . OL-AF.IL ,, - <br />I)ate: <br />-? .-lO,l!'\ <br />Site-Work <br />Underground <br />Pole Bases <br />Light Standards <br />Spas, Pool, Fountains <br />Signs (monument) <br />Life Safety /Low Voltage <br />Fire Alarm I Dampers <br />Communications Cable <br />Building <br />Under Slab / Floor <br />Bonding I Grounding / UFER <br />Transformers <br />Torquing <br />Sub-Panels <br />Air Conditioners <br />Roof Top Equipment <br />Factory Wired Unit <br />Walls (Conduit) <br />Walls (Rough) <br />Ceilings (Hard & Soffit Rough <br />Ceilings (T-Bar Rough) <br />Meter Release EvEITf lEh <br />hrtt I I \L-g <br />Rough ntrn tn ,nn <br />Service lVleter t)n <br />FINAL jAMU U-43, 2S 0, 556, 667 ')MIM) <br />Notes, Remarks, Etc.vu \l-/