101105208 - Permit - Laserfiche WebLink

Home Browse Search

BUILDING. !NSPECTOR RECORD SITE-WORK DATE ID/SIG.COMMENTS OWNER BTIILDER DELCARATION I hcrcby atfirrn undcr pcnalry of perjury that I am exempt from thc Contractors' License law for thc following rcason (Scc.703l]5 Busincss and Profcssion Codc): Any City or County which rcquircs a permit to construct, altcr. improvc, dcmolish or repair any structurc. prior to its issuarrcc, also requircs thc applicant for such pcrmit to file a signcd stalcmcnt that hc or she is liccnscd pursuant to thc provisions of the Contractor's Liccnsed law (Chapter 9, Comnrcncing with Section 7000 of Division 3 of the Business and Profcssions Codc) or that he or shc is cxcmpt thcrcfrom and the basis for thc allegcd cxernption. Any violation of Section 7031 .5 by /ny applicant for a pcrmit subjects the applicant to a civil penalty of not morc than five hundred dollars ($50O). _1. as owncr of thc propcrly. or my cmployccs with wagcs as thcir sole compcnsatiorr. will do thc work and thc structuc ls nol intcndcd or offered for salc (Scc.7O44. Busincss and hofessions Codc: The Contractor's Liccnse law does not apply to an owncr of thc proprty who builds or intprovcs thcrcon, and who docs such work hinrsclf or herself or through his or her own cmployccs, providcd that such improvcnrnts are nol intcndcd or offcrcd for sah. lf, howcr,rr. thc buiHing or irprovcnrcnt is sold within one )car of corrrplctio[ thc Owncr Buildcr will have the burden of proving that hc or she dkl not build or irrqrrove the propcrty for thc purynsc of salc). -1. as owncr of thc property, am cxclusivcly contracting with licensrd contrBctors lo conslruct the projcct (Scc. 7O[4. Business and ltofcssion Code: Thc Contractor's Licensc Law docs not apply lo an owncr of property who builds or irnproves thereon, and who contracts lbr such projccts with a Contractor(s) liccnscd pursuant to thc Contraclor's Liccnsc [:w). _l am cxempt under Section_, B. & P.C. for this rcason. I):rtt' ( )rr lrt'r WORKERS' COMPENSATION DECLARATION I hcrcby affirm undcr pcnalty of pcrjury one of thc following derclarations: -l havc and will maintain a Ccrtificate of Conscnt to Sclf-lnsure for workcrs' compensation, as p,rovidcd for by Scction 3700 of the l-abor Codc. for thc lrcrfornunce of thc work for which thc pcrmit ls issued. (pur" and will maintain workers' compensation insurarrce. as rcquired by Section 3700 of the l-abor Code. tbr the pcrformance of thc Pork for which this permit is issucd. My workcrs' comfrcnsation insurancc carricr and plicy numbcr are: carricr: 5 +'.-k Ctr-oc*! e.lr- n Poricy Nu^t*r,1 Lf tlqf - 11 Expircs:v/q/zt _l ccnify that in the pcrforrrance of thc work for which this permit rs issucd. I shall not employ any person in any rurnner so as to bcconrc subject to the workers' compcnsation laws of California. and agrce that if I should beconre subject to thc workcrs' conrpensation provisions of Scction 3700 of the l,abor Codc. I shall. forthwith comply with thosc provisions. WARNING: Failure lo securc workers' compcns:ltion covcrage is unlawful. and shall subict an employer lo criminal pcnaltics and civil fincs up to one hundrcd thousand dollars ($100.000), in addition to the cost of compensation. damages as provided for the Scction 3076 of thc Labor Codc. intercst and attorncy's fecs. Datez / / -/Z- ZO NECI ARATION I hcrcby affirrn undcr pcnalty of pcrjury that I am liccnscd undcr provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 of thc Busrncss and Professions Codc. ad my licensc is in full force ard cffcrt. License c, 1 Nurnhr:/of1Zq7 a conrracto ,, tt /* - k f* L - .//*o CL,,4. - , RooA^s CONSTRUCTION LENDING AGENCY I hcrcby affirm undcr lEnalty of prjury thal thcrc is a @nstruction lcnding rgercy for thc pcrformc of thc work for which this JErmit ir isscd (Ss.3097, Civ. C.). lrndcr's Nam: Lrndcr's Addrcss: APPLICANT NECLARATION I trcrcby affinn undcr pcnalty of pcrjury onc of thc following declarations: Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Part6) -Rcquircd lrttcr of Notification _l ccrtify thal thc fcderal repulations rcgarding asbestos rcnrovalare nol applicablc to this projc.ct. l'ernttlee natrre + Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor S u bf loor/VenVl ns u latio n Roof Sheathinq ll'to?e DU,//JI ,%' Shear Wall Framinq Insulation/Energy Drywall Ext./lnt. Lath Brown Coat [\Iason ry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif nl .a, F!NAL 17'v-20 tlru,/@ th 6t Certificate of Occupancy Noles, Rema,rks, Etc.,l A/ T Rev. 08-07-201 5 l