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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS owNuR l|U[.t)Ett I)Iil,( Al{A'IloN IhercbyaflirmunderpcnaltyofperjurythatImexemptfromthcContractors License[-awforthefollorvingrmon(Se.7031.5 Businss md Profcsion Code): Any City or County which requira a pcmit lo construct. allo. improve, detnolish or repair any slruclure. Frior to ils isumce. also requirG the applicant for such pmnit to file a signed statemenl that he or she is licensed puEuilt to lhc provisions ofthe Contraclor's Licensed law (Chaptq I, Cormencing with Seclion 7000 ofDivision 3 ofthe Busincss md l,rofe$ions Code) or lhat he or shc is exempt thdefiom Md the b6is for the alleged crmplion. Any violation ots6tion 70,11.5 by any applicanlforapmnitsubjcctsthe applicanttoacivilpenaltyofnotmorclhanfivehundreddollus($500). _1, o orvno of the prorErly. or my employs wilh wag6 6 their sle conrpflsalion. will do thc work ud the structue is not intmdql or offsed for ste (Se.7044, Businas ad Profesions Codc: 'Ihe Contrsclor's l,icnse taw do6 nol spply to d oMs of the preFrty who builds or improra thoon. md who doc such ro* himself or hmelf or through his or ho om entployee. provided that such improvflmts de not intmded oroffoed for sle. If, howwq. the building or improvonent is sold within one )s ofcompletion, the Grner Buildq will have the btudm ofproving that he or she did not build or improve the propsty for the purpos of sale). _1. N owns of the prcpqty. an exclusively contracting wilh licensed contractoE to comtruct the prei6t (Se. 7044, Busins and ProfqsionCode:TheContractor'sLiccnscLawdo6nolapplytomownsofpropertywhobuildsorfunprovslhs@n. and who contracls for such projms with a Contrado(s) licmed purs@t to lhe Conlraclor's Licme [aw). I an cxernpl unds Section-. B. & P.C. for this r6on. l)ate ()sncrl I hreby affirm undo penalty ofpqjury one ofthe following _l have md will mainlain a Cffificate of Co$mt to Self-l$ure for workcrs' conrpensation, 6 Fovided for by Sstion 3700 of the kbor Code. for the pqfomoce of the work for which the pennit is issued. -l havc and will maintain workers compensalion insurance. as rcquircd by I the *ork for which this pmnit is isued. My workers' compmsation iuuruce Sslion 3700 ofthe Labor Codc. for lhe psfonnmce of cmier md policy number ue: Policv Numbs: Expires: - _l cenify lhat in the psformance of the work for which this pennil is issued. I shall not employ any person in any marnq rc otobecomesubjrttothework6s'compesdionlawsofCalifomia.ildagtwthatiflshouldbecome subjecttothe workq-s'composatiooprovisionsofSection-lT00ofthetaborCodelshall,fonhwithcomplywiththosprovisions. WARNTNG: Failure to sue workm' compmation covmge is unlarvful. and shall subjat m onploye to qiminal petElli6 ild civil fine up to one hund,ed lhouwd dollm ($100.000). in addition to the cosl of compensalion. danages o provided for the Section 1076 ofthe Labor Code. inttrBt md altorney's fees. Dxte:-_- Appliqnl: LICENSED CON'TRAC'I'OR DECI.ASAIION I hoeby allmr undo pmahy ofpsjury lhal I m licorul undo provision ofchaplq 9 (commencing with Section 7000) of Division 3 of the Busins and Professiom Code. od my liceme is in full force md effel. Licemc Class:-Liceme Numbq: Da(e: Cotr(rac(or: CONSTRUCTION LT'NDING ACFN('Y I hreby affrrn undo penally of pqjury that thqe is a co[slrlclion loding agency for lhe psfonnoce ofthe work for which this psmit is issued (Sec. 3097, Civ. C.). Lendrr's Narne Lender's Ad&s: ATILICANLDECI.ABAIIAN I hqtby amm undq penalty of pqjury one ofthe follorving drlaations: Demolition Psrnits-Asbeslos Notification Fcderal Regulations ('l itle 40. Pa16) -Required Lelter of Nolification -l cdiry that lhe federal regulatioN regdding abestos rernoval oe nol applicable to lhis project. I cenify thal I have rcad this application md slate that the abovc infomation is corffl. I agre lo conrply f this City u ith all City and County and ('ounty to entq u[x)n theordirancB ild Stalc LnNs relating to above nlentioned property for ffnnti""ut o. ag"nr L, l- Pemitce nNmc (print): conslruclion. ild hereby authorizc reprsentatives o l)rlc:'./4/L Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUl nsu lation Roof Sheathinq Shear Wall Framinq fflp/rq .CGil,) lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif FINAL 6l{l r1 ,..ra / rt, Certificate of Occupancy Notes, Remarks, Etc. f \