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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARA'IION <br />i hsety amrm undo pflalty of perjury that I m cxempt firm lhe ContractoN' Licose Law for the following re6on (5(.7031.5 <br />Busine: md Professfun Code): Any City or County which requirm a pmnit to cons(ruc1. alta, improvc. dmolish or repair my <br />struclue. pior to its isumce. also requires the applicant for such pmit to lile a si8ned statmmt that he or shc is licensed pmumt <br />to the provisions of the Contraclor's Licensed Larv (Chapte 9. Commencing with Sslion 7000 of Division 3 ofthe Business md <br />ProfcssionsCode)orrhathcorsheisercmptthse6omildlheb6isforlheallegcderernption. AnyviolarionofsetionT03l.5byafi <br />applicantlorapnnitsubjeclslhe applicanltoacivilpenaltyofnotmorelhmfivehundreddollars($500). <br />_1. o owner of the prope(y. or my employe with wags ro their $le comptrsation, willdo lhe work ad the struclue is rcl <br />intodql oroffcredforsle(Se.T044.llusinasmdProfesionsCode:TheContractor'sLicense[,awdosnotapplytoilowntrof <br />theprefsry \uhobuildsorimprovethson.udrvhodoesuchworkhinselforherselforthroughhisorhoownemployee. <br />provided thnt su.h im[rovon€nts ile not intmded or offsed for sale. It howilq, lhe tuilding or irnprovmfit is $ld within one ya <br />ofcompldron. the Owner Buildq rvill have the h.rdm ofproving that he or she did not build or irprove the popqty for the purpo* of <br />slc). <br />l. as owner ofthe propoly. iln exclusively contractinli with licensed contmctoE to construcl lhe projst (S(. 7044. Businas <br />and Pnrf*ionCodc:TheContractor'sLiccnsc[-a!vdo6notipplytomowncrofproperlywhobuildsorirnproveslhseon. <br />and rvho contrads for such projets with a Conlraclo(s) licensed pursuanl to the Contractor's l,icmse Law). <br />-,1 <br />an exempl unds Section--. B. & P.C. for this r6on. <br />Date:_ Owtrer:__ <br />WORKI]RS' COIlI PENSATION <br />I)ECL-ARA'IION <br />I hseby alfirm under pcnalty ofpujury onc ofthe following declaatiors: <br />I have md will maintain a Cmrficate of Consmt to Selt:lmure for workc compssation. c povidcd for by S(tron 3700 of thc <br />Labor Code, for the psfonnmce of the work fot rvhich the ponit is sued. <br />I have and will mainlain workss'b)'Sstion 3700 of the Labor Code. for the pqfommce of <br />the uork ,br which this is issued.cmio md policy nunrbu ae: <br />Carrcr:nI-\)l,(*1,o -7 <br />Erpires: -_ <br />I cffiry that in the pofonnance of the wotk ftrr which this I shall rot employ any pmon in any maner <br />so s lo bccome subjcct to the workm' compensation laws agre thal ifl should beconre subjfft to the <br />workm' compmsation provisions of Sction 1700 of the I shail. l'of,huith with those provrsions. <br />WARNINGT Failure lo sccurc $orkers'unlarvful. and to qirninal psraltiG ild <br />civil fincs up thousand rlollats to the cosl o provided for thc <br />Seclion 1076 Code. interel ald <br />I hoel'y aflirrn undo panalty ofperjury lhat I m licensl 9 (cornmencing with Section 7000) of Division 3 <br />of the llusins od Profesions Code. md uy license is in full md effct. <br />License Class: <br />I)alo <br />CONSTRUCTION LENDINC AGENCY <br />I hreby aflrnr undo penalty of psjury that lhqe is a construclion lending agocy for the pqfommce of the work for which this pcnnit is <br />issued (Se. 3097, Civ. C.). <br />Lender's Namc: <br />[,mdq s Address: <br />APPLICAN'I' DECLARATION <br />I hrcby alfirrn under penalty of pojury one of the following dalrations: <br />Denrolition Perilrits-Asbcstos Notification i:eder,rl Regulations (Titlc 40. Part6) <br />__Rcquired l-elter of Notillcation <br />_ I cmify lhnl lhc laderal re8ulal reSiddins not applicable to this project. <br />L-J cstify that I have read lhis lhat the is corcct. I agre to cornply wilh all City and County <br />ordinanc6 aild Slatc [,arvs rclating building nrrl of this City md @tq uFpnthe <br />t\abovc mcntioncd propeny for <br />Applirant or Agent Sign{ture: <br />Itermilec tramc 6iac--Pa <br />IZ n <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 3/r*/zt .-Wv,) <br />Certificate of <br />Notes, Remarks, Etc. <br />( <br />eelrsyNumbcr: (& l <br />Ditel