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ID/S!G.COMMENTSSITE-WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Z'zi/zo .tZ e rs^,*r,ZO< 2)Framinq
<br />lnsulation/Enerqy
<br />Drywall )a 7r-2,/D
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />FINAL 9./s./t,t /Z( " s,,/r./U\ ){h
<br />Certificate of Occupancy / t
<br />Notes, Remarks, Etc.
<br />r\,o bvre-La-
<br />C'. 37.2?7*:-56
<br />r J//D
<br />I hereby affirnl uDder penalty of perjury that I m exenpt from the Contraclos' License Law for lhe following reason (5@.7031.5
<br />Busincss and Prolession Code): Any Cily or Counly which rcquires a pcrrnit 10 conslruct, ahcr, irnprove. demolish or repair any
<br />structure, prior to its issuance. aLlo rcquires the applicant tbr such pernit to file a sigDed statement that lrc or she is licensd putsuant
<br />to lhe provisions of lhc Conlractor's l-ic€nscd Law (Chapter 9, Commencing wilh Section 7000 ol'Division 3 ol-thc Business and
<br />PrctessionsCode)orlhatheorsheisexemptthereliomandthcbasisfbrtheallcgedexenrpti<rr. AnyviolationofscclionT03l.5byany
<br />applicantforapermitsubjeclsthe npplicanttoacivilpenxltyofnotmorelhatrfivehundreddollars($5(x)).
<br />J41. n*n". nf,h" proFE(y, or rny employees wilh wages as their sole compensation, will do the work and the structurc is nol
<br />iitcnded or offered for sale (Se.7(H4, Business and Prrfesshns Code: The Contraolor's Licensc Law does nol apply lo an owner of
<br />theprcpcfly wlDbuildsorimprovesthermn,andwhodoessuchworkhimselforherselforthroughhisorherownemploy*s,
<br />provided that such improverrcnts are not itrcnded or ollcrcd for salc. Il, howevcr, the building or improvcmnt is sold within one yea(
<br />ofcompletion, the Owner Builder will have the burden ofprcvin! that he or she did not build or improve the prclEfly for the purlre of
<br />sale).
<br />f". o*n", uIthe propeny, am exclusively conlracting wilh licensed conlraclors lo conslruct lhe poject (Sec. 7044, Business
<br />and holLssioDCodc:TheContracbr'sLicenseLawdoesnotapplybanownerofpropenywhohuildsorinrprovesthercon.
<br />and who conu'acts for such proiects wilh a Contractor(s) licensed pursuml lo thc Contraclor's Liccnse Law).
<br />-IanrexenptUndefSection-,B,&P,C,lirrthisrcasrrrr,
<br />"".,71?p/b,>W0RK!]RS' C0MPT]NSA'I'ION
<br />DECI-ARATIoN
<br />tblhwing (lecllrations:I hcrcby allirm u ndcr pcnAhy of pcrjury onc of t he
<br />_l have ud will nraiilain a Ceililicate of Consent to Self:Insure for workers' compensation, as prcvided for hy Section 3700 of the
<br />Labor Codc, for thc performancc o[rhc work lbr which lhc permil is issued.
<br />_l have and will maintain workers compensation iDsurance, as required by Section 3700 ot' the Labor Code, for the perfomrance of
<br />(hc work ti)r which this pcrmit is issucd. My workcrs' compcnsalion insurnncc cafiicr ffil Imlicy numh(r uc:
<br />Policy Nurnher: Expires: _
<br />_l cctrify tlrat in thc perfbrnunce of the tr,ork for which this pcrmit is issucd, I shall not enrploy uny pcrson in any manncr
<br />so a\ 1o bccorrc subjcct to lhc workcrs' cotrrpensation laws of Calilor0ia, and agrce lhat iI I slnuld bccorrc subjcct lo the
<br />workers' conrlrcnsation provisions of Section 3700 of the Labor Code, I shall, fonhwith comply with thos provisions.
<br />WARNINC: Failure k) securc workers'compcnsation covcmgc is unlawful, and slrall subjcct an cmploycr to criminal pcnaltics anrl
<br />civil fiilcs up to one hundred thousand dollars ($100,fi)0), in addilion to the cosl olconrpensation, darnages ns provided for lhe
<br />Section -'1076 ofthe Lak)r Cbde, interest and ailorney's fees.
<br />LICENSED CONTR CToR
<br />DECLARATION
<br />I hereby al-lirm undcr penalty ol pcrjury that I arn licenscd under provision ol ChAptcr 9 (cornmcncing with Scclion 7000) of I)ivision I
<br />of rhc Busincss and P()fessions Codc. md nrv liccnsc is in full lorcc :nd cfTcct.
<br />License Clnssr_Liccnsc Number:
<br />CONSTRT]CTION I,ENDING AGT]NCY
<br />I heEby aflirm under lEnalty of perjury that there is a constnrctioil leildilrg agency for the performance ofthe work fbr which this pernrit is
<br />issued (Scc.3097, Civ. C.).
<br />lf,nder's Nanrc:
<br />I-cn(lcr's Addrcss:
<br />,\PI't,t('''\N'r t)u('t,Att,\'iloN
<br />I hercby aflrnlunder penalty ofperjury one ofthe followinS declarations:
<br />Denrclition Permits-Asb€stos Notification Federal Regulations (Title.l0, Pan6)
<br />_Required btler of Notification
<br />_t certify that the fideral regulati()ns regdding asbesk)s removal are Dot upplicable to lhis project.
<br />_l ce(ify that I have read this applicalion and state that lhe above infornration is conect. I agree 1o conrply with all City and County
<br />atx)!e nlcnli()nr(l propc(y li)r inspcction e ^2- z7-Appli(ant or Agcnt I
<br />Prrmilec narne (prlnl):
<br />BTIILDI}}G. INSPECTOR RECORD
<br />08-07-201 5
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