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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS OWNT]R BUILDER DELCARATION <br />I hocbl al'lirm undo peralty of pqjury lhat I an erempt ,iom th€ Contraclo6' Licmse Law for the following re@n (Ss.703 1.5 <br />tsusincss anC Profesion Codclr Any City or County which requires a pmnit to constnrct, alta, improve, dmolish or rcpair any <br />struclure. prior lo ils i$uece. alco rcquirE thc applicmt for such pemit to file a signed statcmol lhal he or she is licmoJ pusumt <br />to lhc plovisions ol the Contractor's l,icenscd taw (Chaptq 9, Commencing rvith Strtion 7000 of Divisioli -1 of the Busines md <br />ProfcssiorsCode)orlhatheorsheisexemplthqefromildthcb6isfortheallcgedcxmptjon. AnyviolalionofsstionT03l.5byany <br />applicinlforapmnilsubjstslhe applicanttoacivilpenaltyofnotmorelhanlivehundreddollos($500). <br />I, o o$no of lhc prolEdy. or rny employeG wilh wags 6 their sle compwtion. will do lhe work md lhe srruduc 6 nol <br />intodsl or offsed for slc (Sa.7044. Busins md Professions Codc: The Contractor's Licme larv do6 not apply to u oMs of <br />thcpmpeny whobuil&orimprovelhtron.mdwhodo6suchworkhirnselforherselforthroughhisorherownemploycs. <br />provided that such improvmtrls uc ft)r intmdcd or offtrcd for sle. ll. hou'*s. the building or improvonst is $ld within on. tqr <br />ofcornpldion. the Gvns Buildg will have the hrd6 ofproving lhd he or she did not boild or improve the prc1ry for the purpos of <br />sale). <br />-1, <br />o ownq of the propay. m cxclusivcly contracting *ith licfficd contractos to construct the prejcct (Sec. 7044, Buines <br />md Prcf6sicnCode:TheContractor'sLicenseLawdo6notapplylomownsofpropertywhobuildsorimproveslhsmn. <br />md who contrads for such projecrs with a Contmcto(s) licffied p[su@t lo lhe Contractor's Licmsc Lau1. <br />_i an exempt Sction__. B. & P.C. firr lhis rruon. <br />Dale:Owtrer:_ <br />WORKERS'COMPENSATION <br />DECLARATION <br />I hqcby affirm under poalty of pqjury one of the following dcclaatioN: <br />-l <br />have md will maintain a Cenificate of Consent to Sclf-lmure for workqs' compqrsation. as provided for by Setion 3700 of th€ <br />labor Code. for the psfomacc of the work for which the pmnit is issued. <br />flhaveandwrllmaintainworkers compemationinsurance.m requiredbySectionlTO0ofthcLaborCodc,forthepofonnmceof <br />0re *ork for which this pmit is isuql. My workm' compmulion irourace cmier md policy numba re: <br />c**,,-Slatr9 6qafD <br />PolicyNumbs: qlV (}2-bq Expires: _\a - t€4' 2b <br />-l <br />cenify that in the perforrnance of the work for shich lhis pemlil is issued. I shall not anploy any pmon in my mmna <br />so 6 to becomc subjecl to thc work6'compemation larvs ofCalifomia. md agree that ifl should b€comc subjcct to the <br />workss' comlremlion provisions of Setion ]700 of the Labor Code. I shall. forthwith comply with thos provisiom. <br />WARNING: Failure to wue workm'compwtion covera8e is unlawful. aod shall subjet m anployo to oiminal penaltic md <br />civil lines up to onc hundrcd thousand dollars ($100.000).addition to thc cosl of danages a provided fot the <br />Section l0?6 of thc t-a[{r Codc. intcrLst md fea. <br />DECLARA'TTON <br />I hocby affirrn undo poalty of psjury that I an licerued undr provision of Chapto 9 (comencidg wilh Scction 7000) of Division 3 <br />of the Busirlcs ild Profmicrro Codc. ad rny licosc is in full force dd effet. <br />L- vq q c{2-1(aO <br />Licensc Clas: <br />CONSTRUCTION LENDINC AGENCY <br />I hereby affinn under Frf,alty of perjury lhat th6e is a comtruclion lending aSmcy for the psfonnmce of lhe work for rvhich this pemit is <br />issued (Se. 3097, Civ. C.). <br />lrndq's Nme: <br />- <br />tsdq's Addrs: <br />APPLICANT DECLARATION <br />I hscby aflinn undtr poahy of perjury one of the following deldatrcns: <br />Demolition Permits-Asbestos Notification Fcdoal Regulations (Title 40, Pm6) <br />_Requirqi Lcner of Notilicalion <br />-l <br />cqtify lhat lhe fcdgal rcgulatioN reguding oLslos renoval ae not applicable lo this prejEt. <br />md slale lh.l the ah)ve infornation is corect. I agrL! to comply wilh all Cily and Counly <br />conslruction, dd hqeby authorDc reprGtrlativ6 of this Cily ild County to mlq upon the <br />Applicrnt or,\gent *5( \ <br />I'crmilce \\\) \-L\(-A.{ <br />2-lElzD <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation Ir a- <br />Roof Sheathinq / /P/ /aP h/l?t/Jo,6[- <br />Shear Wall lt <br />Framing <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />ltllasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report \ <br />Flood Zone Certif <br />I -t h1 <br />FINAL t.,wI <br />Certificate of Occupancy I I <br />Note arks Etc <br />r, <br />0 <br />lr I <br />I I ll-( <br />I <br />D,re: 4sl.c> <br />- <br />,,,", 4a fzo -ls. <br />21"4w <br />I