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BUILDING. INSPECTOR RECORD SITE.WORK DATE IDiSIG COMMENTS OWNER BUII,DER DI]LCARATION I hocby affrrin undo penalty ofp€rjury lhal I m excmpt fioin the Conlractors Lice6c Law for the following re6on (Sec.70-11.5 Busines and Profssion Code): Any Cily or Counry which require a ponit lo conslruct. alto, tnprove. donolish or repair my struclure. pnor lo its isumce. also requirc lhe applicilt for such p€nnit to file a signed statonent that he or shc is licrucd pusuet lo thc provisions ofthe Contractor's Liccnscd lrw (Chapt6 9, Conlnencing with S*tion 7000 of Division 3 ofthe Business and ProfessionsCodc)orthatheorshcisexemptlhqefromandthebsisfortheallegedexenption. AnyviolationofsstionT0-3l.5byany applicantforapmnitsubjetsthc applicanltoacivilpenaltyofnotmorcthmfivchundreddollas($500). _ l. a omo of the property, or my employ€ wilh wag6 6 their sle compensation, will do the work md lhe struclrc is not intfidqi oroffqedforsle(Se.TO44,BusinsedProfsioNCode: TheConlraclor'sLicruelarvdo6nolapplytoeounsof rheprcperty rvhobuildsorirnprovetha@n,ildwhodo6suchworkhimsclforhesclforlhreughhisorhoownemployce, p.ovidedthalsuch imprcvanentstrenotintmdedoroflqedforsle.If,howwq.thcbuildingorimprovsnentissoldwithinoneyw ofcomplaion. the Orvos Buildq will have lhe budo ofproving that he or she did not huiH or improvc thc prcpqly for the purpos of ele). _i. $ cvns ol the propfiy. ml cxclusively contracling wih licrued contractoB lo coNtruct the prcjet (Ss. 7044, Bsins ud [tofesspnCode:ThcContractor'sLicenseLawdo6oolapplytoanownsofpropstywhobuildsorimprovesth6sn, and v,ho contracts for such projects with a Contracto(s) licmsed pursumt to the Contractor's Licsse Law). I on e\etnpt undq S6tion--, B. & P.C. for lhis r6on. l)tlc. WORI<ERS' COMPENSATION DECLARATION I hereby aflirm unds penalty ofpqjury one ofthe following deluatiom: _l ha\.e 4d \rill maintain a Cmificate of Consot to Selfl6urc for workqs'compenstion. 6 provided for by Sation 3700 of the Labo. Code, for the pqfonnmce of the work for which thc pmit is issued. ZlZhve and *lll maintain workm compemation insurance, s requircd by S&tion 3700 of the kbor Code. for rhe pofonnace o[ ihe work for which this pemit is isucd. My workas' compssation imurece cmio md policy nurnbo ae: c*i.5@ pori.y Nu.b",,_aD0t0L65-L ---'xp,,", -nf3VZo I certify that in lhe pcrformance ofthc Nork for which lhis pqrnit is issued. I shall not empkry any poson in any mmner so m to becomc subjel to the workqs' cornpereat ion larvs of Califomia, md agre thal if I should trcome subjet to the wortss' conrpcmalion provkioils ofSeclion 3700 oflhc tabor Code, I shall. fonhwilh comply wilh thop provisiom. WARNING: failure to sure workers'compeNalion covtrage is unlarvful. md shall subjet m onployr to aiminal pmaltie errd civil fines up tc one hundred lhousmd dollars ($ I 00.000), in addition to the cost of compensation. danages o provided fc,r thc Seclion -1076 ofthe l-au)r Code. inlerest and altomcy's lbes. Applicant: DECt-ARATION I hceby allrnr unde penalty ofpcrjury that I m licmsed undu provision ofchaplo 9 (comrnocing with Section 7000) of Dilision 3 of lhe Busin6s md Professions Code. md my license is in full lorce od effect. i NurntEr._ c3?Liccr,se Datg o t e /Z,t (*r I hcrcby affirm under pqalty ofpcrjury that issucd (Src. 1097. Civ. C.). CONSTRUCTION LENDING ACI'NCY lhqe is a comtnrclion lendintt aSency for the psfonnoce of the work for which this permit is l-cndcr's Namc: Lcndcr's AddrLTs: APPLICANT DECLARATION I lurtry aflinn under pmalty of pdjury one of the following dsltrationsl Dcmolition Psmits-Asb6tos Notification lrcdsal Rcgulations (Title 40. Part6) Requucd ktls of Notification I cslify rhal rhe fedcral regulalioN regtading obctos rernoval ae not applicable to this projet. ,4 raifu t"t I have read this applicaiion drd state that the ak)ve infonnation is corect. I agre to cornply with all City and County- ..rdinanca md State Larvs relalint l. buiiding coEtrualion, md hocby authorize rcprBmtativ6 of this Cily ed County to mtq upon the abovc motionc{ propeny for iNpcctloo LApplic{nt or Agcrt permirN name (prinr,-)(.--Agoa PgaL-r Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bfloor/VenUl nsu lation t Roof Sheathing a o11,0 Shear Wall rl Frarninq lnsulation/Energy Drywall Ext.ilnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Deputy Final Report Engineer Final Report Flood Zone Certif t-l 1^^ FINAL DKT(t6W9 tr7 Certificate of Occupancy Notes, Remarks, Etc. 4 ,,,". .Zf (o f ZO I I I 12t\fwt \,rTy- I I I 7t?917,