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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER RUILDER DELCARAIION <br />I hoeby affinn undr penalty ofperjury that I an erempl from lhe Contraclors License Larv for the following reen (Ss.7031.5 <br />Businss and Prof6sttn Code): Any City or County which requirs a lmnit to construcl. alt6. irnprove. demolish or repair ay <br />strudue.priortoils issuaf,ce.alsorequireslheapplicmtforsuchpqlnittofileasignedslaternfltthalheorsheislicensedlrrsuant <br />lo the provisioN of thc Conlractor's Licensed Law (Chapter 9, Commencing wilh Sslion 7000 of Division 3 of lhe Busincs md <br />Profesions Code) or lhat he or she is exempt lhqefrom ild the b6is ftrr the alleged exmption. Any violation of Srtion 7031.5 by any <br />applicantforapnnitsubj(tsrhe applicanttoacivilpenaltyofnotrnorethanfivehundreddollas(9500).I <br />-1. <br />o orvner of lhe propeny. or my employG wilh $'a86 6 their $le compqsalion. will do the work ed lhe struclue is not <br />intoded oroffsedformle(Se.T044,BusineandProfasiomCode:TheContractor'sLicenseLawdo6notapplylomownerof <br />theprcpfiy whobuillsorirnprovsthqon.edwhodo6suchwoilhimselforherselforthroughhisorhqowncmployes, <br />providcd thal such improvmmts de not intmded oroffsql for sle. l[ horvo'o. the building or improvencnt is mld rvithin one ]q <br />ofcompldion. the Owns Buildq rvill have the bordm ofproving thd he or she did not build or irnprove the prcpsty for the purposof <br />ele). <br />-1. <br />6 owns of the propqty, m exclusively contracting with licemed contractoE to coElrxct lhe proj(l (S@. 7044, B6ins <br />ad ProfosionCode:'l'heConlraclor'sLicenscLawdo6notapplyloaorvnoofpropertylvhobuildsorimprovesthq@n. <br />and who contracts for such projats with a Contmclo(s) licmed purs@t to lhe Conlractor's Licse Law). <br />_l dr ereinpt undq Setion_. Il. & P.C. for this reaon. <br />l)tlt: ()N trrr: <br />WORK!]RS' COMPENSA'I'ION <br />DECLARATION <br />I heretry aflirrn undo pcnalty ofpojury one ofthe follo\t'ing drcltrations: <br />-l <br />have rutd will mainlain a Cert ificate of Consent lo Sel [- lnsure [or workers' conrpensation, o provided for by Section 3700 o f the <br />Labor Cclde. for the pefonnmce of the work for which the pmnit is issued. <br />-l <br />have and rvill mainlain workers compensation insurance. c reluired by Scction J700 ofthc Labor Code. for the pqfonndce of <br />the work for which this permit is issued. My workers' composation insurance canier md policy numbo de: <br />Policy Nunrbcr: Expires: <br />-l <br />cffify lhat in the perfonnance of the rvork for which this ;rerrnit is issued. I shall not crnploy any person in any milntr <br />e 6tobctonresubj(tlotheworkm'compmsationlawsofCalifomia.mdasr€lhatiflshouldbecomcsubjetbthe <br />workqs' compensation provisions ofSfftion 3700 oflhe t,atnr Codc, I shall. forthwith conlply rvith thos provisions. <br />WARNINC: Failure lo wue worktrs'compcnsalion covsage is unlaw'ful. af,d shall subjecl m sDployer to oirninal petraltiq od <br />civil lines up to one hundred thousdd dollm ($100.000), in addition to the cost of cornpemtion. darrages c prorided for the <br />Sstion 3076 of the Labor Code. inttrGt ed attorney's [s.(L8 )n.ro._4 <br />I hcreby afl'irm undcr penally ofpcljury that I dn licensL{ under provision 9 (comnrencing with Section 7000) of Divisim l <br />of thc Busines md Profsiom Code. md rny licme is in full force dd effsl. <br />I.iccme Class:-Liceme Nurnbq: <br />Drte:_ -_Contractor:C ]AA r7n* <br />I heeby afhm undr poralty of perjury that th6e is a construction loding agmcy for lhe pa'fomuce of the work for which this perrnit is <br />issued (Ss. 3097, Civ. C.). <br />Lender's Name <br />[,ender's Addrs: <br />APPLI(:ANT DECLARA'TION <br />I hotby allnr undo penalty of pojury one ofthe following dsltrations: <br />Dernolilion Psmits-Asbatos Nolification Fedqal Regulations (Title 40, Pa16) <br />-Required <br />Lettcr of Notification <br />-l <br />cffify that the fedoalregulations regading cbctos removal are not applicable to this prejdt. <br />-l <br />cfiify lhal I have rcad this application ard slale that the atnve inforrnation is coret. I agrlt lo cornply rvilh all City and County <br />ordinancs md State Laws relating to building conslruction. md hereby authorize reprBmtatives oIlhis City and Counly to flt6 uB]n the <br />atrve mentioned prope(y for inspclion <br />Applics[t or Agetrt Signxltrre:. <br />I'ernilee nirnc (prinl): <br />puaposG.ol!4 ,,,",/- 7r- 1< <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenVl nsu lation <br />Roof Sheathinq 7-lz-r 7 7?/c?2 ) <br />Shear Wall <br />Framing <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 i1.t 1. / 7 'Z1s/r&:{?7 ) <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />.') ,/4 /1 <br />Z -//-/ q L/q-.,L /,/ <br />€D7