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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER AUILDER DELCARA'I'ION <br />I hoeby aflirnr unde pmalty of pejury that I en exempl from the Conlrack)B [,icense Law for the follorving reNn (Sdc.70-11.5 <br />lJusiness and Profession Code): Any City or ('ounty which requirs a pmnit to construct, altq, imprgve, donolieh or rcpair any <br />slructure. prior lo ils issumce. also requircs the applicant for such pemit to file a signed statemflt that he or she is licenscd pursuait <br />lo lhe provisions ofthc Contractor's Licensed larv (Chapter 9. Commencing wilh Seclion 7000 ofDivisioir 3 ofthc []usincss and <br />ProfcssionsCode)orlhatheorsheiseremptlhsefiomandtheb6isforlheallegcdcxonplion. AnyviolationofSstjrnT0-ll.5byany <br />applicanl for a pemit subj(ts thc applicant to a civ i I penalty of not more thm five hundred dollas ( $500). <br />1.ro orvnsofthepropeny.orrnyernployswithuageatheirmlecompensalion.\'illdothelvorkildthestrudueisnot <br />intmdqj orolTqedforsle(Se.T044.BusinesmdPmfsioNCode:TheContractor'sLic6elnwdo6nolapplyloeo$nffof <br />lheprcfrcfly trhobuildsorimprovBth6@n.mdwhodo6such*orfthimsclforhmelforthroughhisorhoormernployec. <br />provided that such improvqnsls dc not intoded or offsed for sle. lf. ho\'6'q. the building or improvmrot is mld u,ithin onc 1w <br />ofcompldion, the Owrs Buildq rvill have the burdo ofSroving tha he or she did not build or improve the prcpcty for the pu4rcs of <br />sle). <br />l. 6 owner ofthe prcpety. an erclusivcly conlracting with licflsed contraclos b conshlct lhe proiect (Sec. 7(X4, []usincss <br />and holishn(odc:'IheConlractor'sLicenseLawdosnotapplytomowncrofpropcnywhobuildsorinlprovesthereon. <br />and s'lx) contracts for such prejets rvith a Con(racl(n1s) licensed pursuanl lo lhc Contractor's License Law). <br />I an exeillpt undq <br />Dr(e, ] l:--t2l t-? o*n"., <br />I hercby allirm undo poalty ofpojury one ofthc following dclralions: <br />-l <br />have od will maintain a Cdificate ofconsenl lo Self-lNure for workss'cornpensation, s provided for by Sction 3700 of the <br />Lakrr Code, for the gufommce of the rvork for which the pmit is issued. <br />- lhavcandwillmaintainworkffs'compensslioninsurance,d requiredbySeclion3T00oftheLaborCode.forthepofonnanceof <br />the wrrk firr rvhich this pmnit is issued. My workos' compensalion imurance cmier ud ;rlicy numbo re: <br />.,.- 2yerast A)r^ho.. I Easrrra,a 4o <br />eoricyr.runrtro: ?AoGOt(:?->a tbl t,-F,,"., lt/ t / lJ <br />-l <br />cfiify that in the performmce of the work for which lhis pemit is issued. I shall not qnploy any pmon in any mmns <br />s as to become subjsl to the workffi' compfistion larvs of Califomia. and agre lhal if I should become subj(t to the <br />workm' comlmstion provisiom of Setion 3700 of lhe Labor Code. I shall. fonhrvith comply with those provisions. <br />WARNINC: Failure to sue workss'composation covsage is unlarvful. md shall subj*t an mploya to oiminal penaltie and <br />civil finesuptoonehundredthousanddollus($100.000).inaddilionlothecostofcompensalion.dronagesasprovidcdforthc <br />Scction 1076 ofthe Labor Code. interGt md atbrney's fe6. <br />I hoeby atfim undo poalty of psjury thal I on licased undo provision of Chaptd 9 (commmcing with Scrion 7000) of Dirision -1 <br />of the Busins md ProfsioN Code. md my licse is in full force md effet. <br />t-iccmeCtu: 6 <br />"",", llzulll l-icens€ Numberl 1tz14z <br />I hereby alfirm undr penally of pqjury lhal lhtre is a coNtruction lmding agency for the pqfomrmce of lhe work for rvhich this ponit is <br />issucd (S<. 3097. Civ. C.). <br />l-cndcr's Nanre: <br />Lcnd6 s Addrs: <br />APPLICANT DECI.A.RA'IION <br />I hodry alfinn undo penalty ofpsjury one ofthc following dalaations: <br />Demolition P6mits-Asb6tos Notification Fcdcral ReSulations (Tille 40, Pan6) <br />Required Letter of Notification <br />_l colify thal the federal regulations regtrding obestos removal are not applicablc to this prejet. <br />I colify lhal I have read this applicalbn ald slalc tllat the abole infomation is cored. I agre 10 comply wilh all Cily and (hunly <br />ordinancs od Stale Laws relating lo building construclion. ild hqeby authorize relI6oilativ6 of this City md County lo enls utx)il lhe <br />above mcnlioned pmpeny for inspertion <br />Applicnnt or Agent <br />PcrnitN tr{mc (priil(): <br />D"'" 'TlzLlt:l <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Energy <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 />Engineer Final Report <br />Flood Zone Certif <br />FINAL e -24-@ Q,L \91,1€-le3 <br />Certificate of Occupancy <br />Notes, Remarks, Etc. <br />""", llzultl <br />Iatv{-tn