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BUILDING. INSPECTOR RECORD SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDI'R DELCARA'IION II herehy affrm under penalt) ofperjury thal I an ercnrpt from lhc ContracloB' License liw for the following reen (Sec.70-31.5 Businss md P:otbssion Code): Aily City or Counly which requirs a pmnit to consltuct. alt6, improvc. dmolish or repair ey stnrcture. pdor lo its issumce. also requircs the applicmt for such pennit to file a signed stalmcnt that he or she is licmsed pusuut to the provisioN of lhe Contractor's Licenscd Law (Chapts 9, Cornrnencing rvith Srtion 7000 of Division 3 of the Busins ud, ProfessionsCode)orthatheorsheiscxemptthdefromildtheb6isfortheallegcdexenplion- AnyviolationofsalionT0ll.5hyany applicantlbrapmnitsubjslsthe applicanttoacivilpenaltyofnolmorcthdfivehundreddollus($500). __1, :s owncr of ihe prope(y. or my employes wrth wages as their sole cornpensation, will do the work md the structw is not intmdql orollsedforsale(56.T044.BusinssandProfesionsCode:TheContractor'sl,icsselnwdo6nolapplyloanownsof thcprop€rly rvhobuil<lsorimprovethq6n,ddwhodo6suchrvo*himsclforhoselforthroughhisorhoorvnernployco. provided lhat such improvmmls rc not intmdql or offsed for sle. l[ howevff, the building or improvmmt is sld within one yw ofcomplaion. thc Orvns Builds will have the budm ofproving that he or she did not build or improv€ the popsty for the purpos of sle). ._ _1. o os'ner ofthe propcrty. on exclusivcly contracting wilh licensed contractors to construct the projed (Scc. 7044. Buins and hofssonCode:TheConlractor'sl,icense[,awdosnotapplytomownqofpropmywhobuildsorirnprovesthqeon. ard who conrracts for such prejets with a Contracto(s) licosed pursuel to the Contractor's Licmse Law). -l m crempt undq Setion-. B. & P.C. for this r6on Date: 0wner: I hereby aflirrn under penalty ofpsjury one ofthe following I have md $ ill mainlain a Cmificate of Consmt to Self-lnsure for work6s' compmstion. o provided lor by Scction 3700 o f the l.abor Code. for lhe pqfommce of the work for rvhich thc pmit is issued. -l havc and will maintain workqs' compeuation insurance, 6 required by Setion 3700 of the Labor C'ode. for the lvfommce of the uorl for which this pmnit is isuql My workos' compcnsation insurmce cmier md policy numbr ue: ( anicr: Policy Nurnbs: - --Expires: - I ceniry that in the psforilnnce of thc work for which lhis pqf,il is issued. I shall not anploy any pmon in any mmnq so m to bocomc subjct to the sork6s' compmsation laws of Califomia. md agre that if I should become subj@t lo the worktrs' compostion provisions ofSe-tion 3700 ofthc t bor Code. I shall, forthwith comply with lhos provisions. WARNINC: Failurc lo recure workers'compensalion coverage is unlawful. and shall subject m mployu to qtninal pcnali6 ild civil fines up to onc hundrcd thousod dollds ($100.000). in addition lo thc cost of compcmalion. danagc m provided for the Section -]075 of the Labor Code. intqet md attomcy s fm. l)rte: __ Appllmntr_ LICENSED CONTRACTOR DECI.ARATION I hoeby aflirm undo poally ofpsjury that I m licensed undo provision ofChaplu 9 (conunencing with Sction 7000) ofDivision 3 of lhe Busines md Profsioro Code. md rny liceme is in full force md e flflt. Liccroc Clu:-Licme Numbcr: Dste. Contractor: CONSTRUCTION LENDINC ACENCY I hseby a(firm undd penahy of perjury lhat lh6e is a comlruction lmding agmcy for the psfonnmce of the work for which this pqrnit is issued (Sa. 3097, Civ. C.). Lender's Namet - Lerdo's Addr*s: APPLICANT DECLARATION I horbyaffnn undo penalty ofperjury one ofthe following drlaations: Demolilion Psmils-Asbstos Notification Fedoal Regulations (Thle 40. Pd16) -Rcquired tdlo of Notificalion -l certify that the federal .cgulatio$ rcgoding Gbestos rernoval ile nol applicable lo this prcj(t. -l certiry that I have red this application md stale that the abovc infomation is corm. I agre to comply with all City and County ordinancG ud State Laws relaling to building coNttuclio[ ed hqeby authorizc reprGotativs of lhis City md County to otq upon the abovc mcnlioncd property for inspetion pupose. Applicf,nt or Agent Sigtrature: l'ernritee nrme (pri[a)i _ - I)ale: Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/VenUl ns u lation Roof Sheathinq Shear Wall Framinq lnsulation/Enerqy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Enqineer Final Report Flood Zone Certif FINAL f"-10-7)k-ll)'-Jl, Certificate of Occu Rema Etc.