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BUILDING. INSPECTOR RECORD ISITE.WORK DATE ID/SIG.COMMENTS OWNER EUILDER DELCARATTON I hlrchy all-lrm undcr Fnalty of Frjury tha( I nm excmpt lhm lhc Conlraclos' Liccnrc l:w li)r thc tilllowing rca$n (Scc.70.ll.5 Busincss anl Pnrlbssion Crxlc): Any Cily or County which rcquircs a JErmit k conslruct, nlter, improvc, dcmrlish or rcpair any struclurc. prbr lo its issuance, also rcquircs the spplicant li)r such lErmit lo lilc a signcd statercnt thal hc or shc is liccnsd pursuml b thc povisi(xrs ()f lhc Conlraclor's Lienscd Law (Chaptcr 9, Commcncing with Section 7000 of Division -l of lhc Busincss and PmlcssionsCodc)orlhalhcorsheiscxcmptthcrctiomandthchasisli)rthcallcgcdcxempli(rn. AnyviolalionofScclionT0.ll.5byany upplicant ti)r r pcrmil suhjccts thc applicant to a civil pcnalty of ilil nxrrc thdn llvc hundrcd dollars (SsU)). _1, as owncr ot'thc pK)pcrty, or my enrpk)yccs with wagcs as thcir solc comlrcnsrlion. will do lhc work arkl tltc' slru,clurc is not intcnded ()r ofl'ercd lirr salc (Scc.7044. Business and Prol'cssions Crxlc: Thc Contraclor's l-iccnse [-aw does not apply to an owncr of the pnrJrcay who builds or inrproves llrcrcon. and who dtxs such wort himscll'or hcrsclf rlr through his or hcr own cmpl()yces, providcd thal such improvenrcnls arc rxrt furtcndcd or oll'crcd lirr salc. Il, howcvcr, lhc building rlr improvement is sold within onc ycar of conqrletion, the Owner Buildcr will have thc hurtlcn of pnrving that hc or shc did not huikl or impnrvc thc pn)pcrty lbr thc purpose of salc). _1. as ()wncr ol'thc pn)1rcrty. anr cxclusivcly conlracting with and Pnrlbsskln Codc: The Conlractor's License [-uw rlocs not contractors lo construct thc projcct (Scc, 7044. Busincss an owner tlf propcrly who huilds or improves thcrcon. Contractor's Liccnsc Law).and who conlracts tirr such Io lhc _l am cxcmpt undcr lirr this reason. WORK E RS' C]OIVI PENSATI O N DECLARATION I hcrchy all'irm undcr pcnalty ol'Jrcrjury onc ol'thc firllowing dcclaralions: _l havc anl will maintain a Ccrtilicatc ol'Conscnt to Sclt-lnsurc li)r workcrs' comJrcnsation. as pr)vidcd lbr by Sccliott 37t[ of thc Latxlr Crxlc, tor the yrcrlirrmancc of thc work tbr which the pcrmit is issuctl. _l have and will mainlain workers'compcnsation insurancc, as rL'quired byScction 3700of the [-aborCode, tilrthc pcrfirrnunccol' thc wrlrk lirr which this pcrmit is issucd. My workcrs' comlrcnsatkln insurance canier anl pllicy numh*-r arc: Policv Number: Exoires: _l ccrtil'y that in thc Jrcrtormancc o[lhc wrlrk lirr which this Jrcrnrit is issucd, I shall not cmpkry any pcrson in any manncr so aslohc'comcsubjcctlotheworkcrs'conrlrcnsalionlawsot'Calililrnia.andagrccthatil'lshouldbccomcsuhjccttolhe workcrs' contJrcnsation provisions of Section -1700 ol'thc Latxlr Crxle. I shall. tilrlhwith comply wilh thosc pnrvisions. WARNING: Failure t() sccurc workers'conrpcnsalion covcragc is unlawl'ul, and shall subject an cmphlycr to criminal Jrcnalties and civil l'incs up lo onc hundrcd thousand dollars irr Irl cost ol'ion, danhges as providcrl lilr thc Scction J07(r ot'thc Lahrr Cirdc, inlcrcsl antl o,r",-iq -V-/7 DECLARATION I hcrchy aUirm undcr pcnalty ot'pcrjury that I am liccnsctl undcr pnrvision ol'Chapter 9 (commcncing with Scction 7U)()) of Division J of thc Busincss and Prol'cssions Codc, antl my liccnse is in full lirrcc and cl'l'cct. Licensc Class: Liccnse Numher: W I hercby affirm undcr Fnalty ol trcrjury that lherc is a construclion lcnding agcrey for thc lErformancc o[ lhc work fbr which this tmit ir issucd (Scc. 309?, Civ. C.). kndcr's Narc: I-cndcr's Atklrcss: APPLICANT DECLARATTON I hcrcby all-rnr undcr pcnalty ot'Jrcrjury onc of'thc following dcclarations: Dc'molition Permits-Ashcstos Notilication Fcdcral Rcgulations ('titlc 40, Pan6) _Rcqu ircrl lrttcr ol' Not ilication _l ccrtily that lhc t'cdcral rcgulations rcgarrling ashcstos rcnxrvalarc not applicahlc to this projcct. _l ccrlily that I luvc rcad this application zutd slalc that lhc alxrvc inlirrnration is con'cct. I agrcc to comply with all City and Crlunty orrlinanccs and Statc Laws rclating to ol'this City and County lo cntcr uJxln thc ahovc mcntionctl prlpcrly lirr Applicant or Agent Itennilcc narne and hcrcby Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/VenVI nsu !ation )i Roof Sheathinq ///.2 2,//? fra 'OlilU Shear Wall jy'/t/,tr' Pl,rnru ,4 Framinq T /'L,', \ /244 ,ry I lnsulation/Enerqy //fi /2il.t> ti/nre/ac/' Drvwall 1/i/,'14ula 'h ,fn*u4 ti @lnt. Lath /7 I /2t'2,o Fl .4da,./9lilrA- Zldl2o-f/ffrN' Brown Coat /ili lto Pl-rc 'a,-l I I Masonry Pool Fence T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Certif. I I At //'.a F!NAL HldDo urern \qr{ Certificate of Occupancy I t { - 1 rl I