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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG COMMENTS OWNER BUII,DER DELCARA'TION <br />I hqeby affirm undq penalty of perjury that I an exernpt liom the Contracto6' Licqse Law for lhe lbllowinS reen (Se.7031.5 <br />Businss and Profcssion Code): Any City or County which rcquira a po'mit to construcl. aho. irnprove, dmolish or repair oy <br />structure, prior to ils issuance, also requirs the applicant ftrr such pennit to file a signed statemot that hc or shs is licmsed pumuanl <br />Io lhe Eovisions of the Contractor's Licensed Law (Chapt6 g. Comrnencing with Selion TOOO of Division-3 of the Business mri <br />ProfessionsCode)orlhatheorsheisexemplthqefiommdtheb6isfortheallegedexanption. AnyviolationofseclionT03i.5byany <br />applicant for a penuit subjets the applicant to a civil penalty of not morc th6 five hundred dollus ($500). <br />l. as oNmer oithe pnrfErty. or m) employs with wags 6 their sole compcnsation. will do the work md thc slrudue is not <br />iilorded oroffcredfor*le(Se.TC44.BusinasmdProfqsionsCode:TheContraclor'sl.icmscLawdo6notapplytooownqof <br />theprcperty whohuildsorimptovsthqmn,mdwhodo6suchworkhirnselforhersclforthroughhisorhtrowncmployees, <br />provided that such inprovonents ae not intmded oroffoed for slc. l[ howwo. the building ot irnprovqnent is mld within one yo <br />ofcompldion. the Olvner tluilds will have the budm ofproving that he or she did nol build or improve the prcpaty for the purpor of <br />slc'. <br />_1. a ouno ofthc ;rolEly. m exclusively contracting lvith liccnscd contractoG to construct the prcject (Ss. 7044, BNin6s <br />ed Prof6sonCodc:TheContractor'sLicenseLawdo6notapplytomown6ofpropertywhobuildsorimprovesthtr@n. <br />and who conlracts for such projEts with a Contracto(s) licensed pursumt to the Contrack)r's Licens€ Law). <br />I m exempt unds Seclion-, B. & P.C. forthis r6on. <br />Date:_ Owner: <br />WORXERS'COMPENSATION <br />DECLARATTON <br />I hecby affrrm undo pmalty of perjury onc of the following dcleatiom: <br />I have md will maintain a Certificatc ofConsent to Self-lnsure for workqs'compensalion, m provided for by Section 3?00 ofthc <br />LahoTCode. for the pafommce of the uork for which lhe pmrit is issued. <br />t2(haveanduillrnaintainworkes'compensationinsurance,6 requiredbySection-lT00oftheLaborCode.forthepafommceof <br />thc work for rvhich this permit is issued. My workqs' compensalion insurmce cmir ad policy numbe ue: <br />c*;,d<sie Atrytwttot lf-ll:,.. ; totae FJrKJ <br />Iblicy Nunrber:Expires: <br />_l certiry lhat in the perforrnance oflhe work for u'hich lhis pornit is rssued. I shall not ernploy any person in any manna <br />* o to lxcome sulrjet to the work6' compcNalion lass of Califomia. md agree that if I should become subj(t to the <br />rvorkm' ccmpensaltrn provisions ofSetion 1700 oflhe tabr Code. I shall. fodhrvnh comply rvith thos provisions. <br />WARNING: t-ailure to *cue workss'compcDsation covemge is unlaq'fuI. md shall subjet m mployr to oiminal p€naltiG md <br />civil fines up to one hundred thcusand dollars ($100.000), in addition to the cosl compensation. danagcs o provided for thc <br />Secticm 1076 ofthe Latnr Code. inlerest fcs. <br />D,k, I -ia)-')L)){) <br />t)[( 1.,1&\l loN <br />I htrby alfinn und6 penahy ofpsjury thal I an licoseJ undo provision ofChapto 9 (commocing with Section 7000) of Division 3 <br />of the Businss and Prof€ssioru Code. md my licmse is in full force md e ffect. <br />l-icense ?Numher ?T>i{U-lcl <br />-y/*",6an Perlfo 9gn Cornf-qry <br />CONSTRUCTION LENDINC ACENCY <br />I heeby aflinn undo pcrralty of psjury that thfic is a coNtruction lending agmcy for the psfommce of the work for rvhich this pennit is <br />issued (Sec. 3097, Civ. C.). <br />t-ender's Addrss: <br />APPLICANT DECLAR,TTTON <br />I lucty affinn undcr penalty of pojury onc oflhe follorving declaralions: <br />Dcmolition Perrnits-Asbcstos Notification F-ederal Regulations (Tille 40, Ptrt6) <br />Required Lelter <br />_l regulatiore rcgading Gbetos rqnovalae not applicable lo this prcjst. <br />lhal I hil'e read lhis md stale that thc atxrve infonnation is con ect. I agrtr to comply <br />ivs ofthis City <br />with all City and Counly <br />md Counly lo flld upon lheconstruction, md hseby authorize reprsmtat <br />l'ermite naile <br />' rura Nowrro Zfr-?p2t) <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Su bf loor/VenUl nsu lation <br />Roof Sheathinq <br />Shear Wall <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />/rr\ <br />FINAL '1'24-7.t)V-{Lic)\ <br />Certificate of <br />Notes, Remarks, Etc <br />I <br />vl\-/ <br />Lcndcr's Nanrc.