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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DE1,('ARA'IION <br />I hoeby affrrn undm poalty of perjury thal I or erempt fiom thc Conlraclors [-icense La$ for the follou'ing reen (Se.7031.5 <br />Bminas md Profession Code): Any City or County rvhich requira a Jurnit to comlruct, alt6. improve. donolish or repair my <br />slructue. prior lo its isumce. also rcquirG thc applicanl for such pennil Io lile a signed statmmt lhat he or she b licmed pmuat <br />to lhe provisions of lhe Contraclor's Licensed krv (Chapts 9. Comnrencing u'ith Sation 7000 of Division I of the Busines md <br />Profe$ions Code) or that he or she is exempt thsefrorn ild the basis for thc alleged cxonption. Any violalion ofSeclion 703 1.5 by any <br />applicantforapennitsubjetsthe applicanttoacivilpenaltyofnotmorelhilfivehundrcddollos($500). <br />_1. o owner of lhe propeny. or my employ$ wilh \r'ag6 as lheir $le compensalion, silldo the \olk md lhe strudue is not <br />intoded or offsed for sle (5(.70,14. Businss md ProfssioN Codei lhe ('onlrack)r's Licose larv do6 not apply to m owns of <br />theprcpeny rvhobuildsorirnprovethq@n.edwhodo€suchuorkhimselforhrselforthroughhisorhsownemployeE, <br />providcd that such impro\'6nmts de not intoded or offqcd for mle. ll hos'o,s. the trrilding or improvonent is mld $ ithin one yw <br />ofcompletion. the Orvns Buildd will have the burdo ofproving that he or shc did not build or improve the prcpsty for the purpos of <br />ele). <br />_1. o orvncr ofthe propqly. en crclusively contracting tr'ith liccnscd conlractors lo construct the froj(l (Sec. 7044. Busines <br />md Prcfesion Code: The (i)nlractor's License [,arv dos nol apply to m owner ofproperty who builds or improves thermn. <br />and who contrads for such projects rvilh a Contracto(s) liccnsed pursuanl h the ( onlrack)r's l.icensc l-aw). <br />I an exeNpt unds Sstion-, l]. & P.C. for this re6on. <br />I)alo: Owilcr: <br />w()RKrrRs' coNrPliNsA il()N <br />r)lr( L,rRA l loN <br />I herebv afilrrn lndcr pcnalty ofpcr jury onc ol lhc lirlirrvinq (lcclarations: <br />_lhavemdrvillrnaintainaCqtificalcofConsenlloSelf-lnsureforworkers'conlpensalion,as providedforbySection3T00ofthe <br />Labor Code. for the pofomraf,ce ofthe work for which the pmnit is issucd. <br />_l have and rvil I mainlain workers' conrpcnsation insurance. 6 requir ed by Ssl ion -l 700 of the t-abor Codc, for the ptrfonnmce of <br />the work for which this pcnnit is issued. My workers compeNation insurance caFier ad policy nurnbcr ue: <br />any pcrson in any rnanno' <br />so d lo becorne subject to lhe workqs' conrposatioD laws o f Cal ifonria, and alree that if I should becorne subjet to the <br />work6s' compeilsation provisions ofScction 3700 oflhe Lak)r Codc. I shall. forthrvith cornply rvith lhose prcvisions. <br />WARNINCT Failure to sure workss'compffalion coveragc is unlawful. and shall subj(l an onployo to siminal peoahi6 dd <br />civil finesuptoonehundredlhousmddollos($100.000).inadditionbthccostofcompensation.dilnages6providedforthe <br />\"t ^*-K (J <br />I hereby affinn unda penalty ofpqjury thd I m licmsed undo provision ofchaptq 9 (commflcing wilh Section 7000) of Division l <br />of the BusinN ild Profsions Code. od my license is in lull force md effet. <br />f,,..n,.3 c <br />to tg <br />I haeby affmn undo penalty of pfrjury that thqc is a corotruction lading agqcy for the pqfonnmcc of the work for which this pomit b <br />issued (Ss. 1097, Civ. C.). <br />Lender's Name <br />Lender's Addr6s: <br />APPLI(]AN-T I)FCLARA'TION <br />I herby affm under poalty of perjury one ofthe follolving dslilalions: <br />Dernolition Pemits-Asbestos Nolification Fedsal ReBulations ('l itlc 40. Part6) <br />-Required <br />Ldrer of Notifi cation <br />-l <br />cdiry that the federal rcgulations regdding mbtskrs rentrval are not applicable to this prejet. <br />I cerlity that I have read this application erd state thrl thc alx)\'c iilforilration is cons.^l- I aSre lo .omply with all City and County <br />ordinancB md State [,aws relating to building coNtnrction. mtl hcreby authorize rclnGolativcs ofthis City ard County to enttr upon the <br />I above nrentioncd propcny for <br />,X,"," rol"rliX <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bfloor/VenUl nsu lation <br />Roof Sheathinq <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 />Deputv Final Report <br />Enqineer Final Report Y <br />Flood Zone Certif <br />F!NAL /-/L -/g ,/*{d ,O?) <br />Certificate of Occu pancy <br />Notes, Remarks, Etc <br />Sstion <br />Drte:rdlaalp,,\ <br />ll <br />!tr,,",