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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS Set Backs Forms/Steel/Holdowns Erection Pads a/I UFER Ground -<-,*t AuuL< $L@floor'subflqzt/VenUlnsul. //-;Boofsheathing t5l ta/E t\ s,l- Shear Wall /,s-ft'-/15 s",s#vz+ Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif ,t FINAL 6Jbo/tb=fffiiu 'tu-/0d Gertificate of Occupancy vv ll/I Notes, Remarks, Etc. I o t- rll-l Owiler-Uuilder Declaration I hereby affrrm under penalty ofperjury that I am exenrpt form lhe Contractors License lnw for the following reson (sec.?0] 1.5 Businessi and Profesion Code): Any City or County which requircs a permit lo co6lrucl. ahcr. improvc. demolish or rcpair any struc(u.c. prior to its issuance, also rcqutes the applicanl for such pcrmit to file a signed statcmcnt thal he or shc is licensed pursudnt to thc provisions ofthc Conlraclor's Licensed Law (Chapler 9. Conrmencing with Seclion 7000 of Drvision 3 of the Business and Professions Code) or lhal hc or shc is cxcmpt thcrcftom and lhc basis for the sllcgcd cxcmption .Any violation ofSeclion ?0,11.5 by any applicant for a pemit subjccts the applicant to a civil pcnalty ofnot ntorc than fivc hundrcd dolls6 (9500). I. 6 owner oflhc propcny. or my cmployccs with wagc as their solc compensation. will do the work and lhe struclurc is not inlcndcd or offered for sale ( Sec ?044, Business and Professions Code The Contractor's License Law does not apply to on owner ofthe p.opc(y who builds or improvcs lhcrcoo. 8nd who docs such work himsclfor hcEclfor tfuough his or hcr own employccs. providcd lhal such improvcmcnls arc nol inlendcd or offcrcd for sale. If, howcvcr. thc building r improvcment is sold wilhin onc year of complcrion. thc Owncr-Buildcr will havc thc burden ofproving that he or shc not build or improve for lhc purpose ofsalc). _ l. as owncr ofthc propcny. am cxclusivcly contracting with liccnscd contrsctors to comlruct the proiecl ( Scc. 7044. Business and Profession Code: The Contraclor's l-icense Law does not apply to 6n owner ofpropeny who builds or tnproves thereon, and who contracts for such prolects wilh a Contraclo(s) ltcensed pursuanl to the Contraclor's License Law.). _l m cxcmpt und6 Scction _ Dstc:Owncr: WORKERS COMPENSATION DECLARATION I hercby allirnr under pcnalty ofperjury onc ofthe following declaralions: _l have and will maintain a Cenificatc ofConscnt to Self-lnsure for workers'compensation, as provided for by Section 37oo ofthe tabor Codc. for the pcrformance ofthc work for which the permit is issucd. -l have and will maintain workers' compenslion insurance, as required by Section -'1700 ofthe kbor Code, for the perfornrance ofthe work for which this permit is issued My workers' compenstion insurance canicr and policy number arc: _.8. & P.C. for this reason. Can'icr: Policy Numbcr:__Expires: ('lhis seclion need nor be completed ifrhe perrnil is firr One hundred dollam l$1001 or less) I ce(ify lhal in lhe performance ofthe work for which this pennit is issued, I shall not employ any person in any nranner so as k) became sublect to the workers ' conrpenstion laws ofCalifornia, and agree that ifl should become lo the workers' those I. and shall an employer kr crirninal fnlahics and civil damgcs u ptovidcd for thc Strtion 3076 of 4 LICENSf D ('ONTRA('TORS DE('LARATION I hercby affirm under penalty of pcriury that I am liccnsed undcr provision of Chapler g (comrncncing with Section 7000) of l)ivision -1 of the Business and Professioro Code, and my licensc is in full force and cffect. fincs up lo onc hundred thousand dolla6 ($100.000).in addition to thc cosl the Lahor Code. rnterest and sttorney s fees a Liccnsc Number /1/License Dale: Lender's Namer _ Conlractor: ofperjury thal lhcre is a coNtruction lcnding agcncy ofthc work for which Ihis pcrmit is + Lender's Address: APPLICANT'S DECLARATION Demolition Pcrmils-Asbestos Notillcation ledeml Rcgulations (Tille 40. Pan 6) _ Rcquircd Leller ofNolificstion _l ce(ify that the federal rcgulations regarding obestos removal arc not applicable to this projcct. I ce(iry that I havc rcad lhis application and statc that thc abovc infomation is conect. I agrce to comply with all City and Counly ordinEnces snd State Ldws rclating to building cofflruction. and representativcs ofthis City and Counly to enlcr upon lhe sbovc mentioned propcny for inspetion [)ale:LApplicant or agcnt sig. Peflnittee name (print) Applicanll