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SITE-WORK DATE ID/SIG. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />SubfloorNent/lnsulation <br />Roof Sheathinq <br />Shear Wall <br />Framinq <br />Insulation/Energy <br />Drvwall <br />Ext.lint. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Cert if. <br />1 I I- <br />FINAL "Z..\n \\b ~')9-.~ <br />Certificate of Occupancy . - <br />Notes , Remarks, Etc. <br />BUILDING-INSPECTOR RECORD --COMMENTS OWNER BU ILDER DEL CARATI ON <br />I hereby affmn under penalty of perjury thal I am exempt from th e Contractors' License Law for the fo llowing reac.on (Sec.7031.5 <br />Bus iness and Professio n Code): Any City or County which requires a pcnnit to construct. alter, improve. demolish or repair uny <br />Slructure, prior to its issuance, also requires the applicant for s uch pennit to file a signed statement that he or she is licensed pursuant <br />to the provisions of the Contractor's Licensed Law (Chapter 9, Commencing with Section 7000 of Divis ion 3 '51 the Business and <br />Professions Code) or that he or she is exempt th erefrom and t he basis for the alleged exemption. Any violation of Section 70ll .5 ~>y any <br />applicant for a pem1it subjects the app licant to a civi l pcaalty of not more than five hundred dollars ($500). <br />_I. as owner of the property, or my employees with wages as t heir sole compensatio n. will do the work and the suucture is not <br />intended or offered for sale (Sec, 7044. Business and Professions Code: The Contr actor's License Law does not apply to an owner of <br />the property who builds or improves thereon. and who doe; such work himself or herself or through his or her own employees. <br />provided that such improvements are not intended or offered for sale. If. however, the building or improvement is sold within one year <br />of compk.1ion. the O.vner Builder will have the burden of proving that he or she did not build or improve the propaty for the purpose of <br />sale). <br />_I. as owner of the property. am excl us ive ly contracting with lice nsed contractors to construct the project (Sec. 7044. Business <br />and Profession Code: The Contractor 's License Law does not ap ply to an owner of property who bui lds or imp roves thereon, <br />and who contracts for such proJccts with a Co ntracto,{s) licensed pursuant to the Contractor's License y <br />Da t~runexempt undcrScc11on / l '{Bj~c;;;;;t}/A/tiJJI\ ~ • <br />KllRS' CO~IPll~.T ION C <br />DECLARATION <br />I hereby affirm under penalty of perJury vmg declarat1011s <br />_I have and will mamtam a Certificate o f Consent to Self-lnsure for workers· compensation. as provided for by Section 3700 of the <br />Labor Code. for the perfonnance o f the wo rk for which th e permit is issued. <br />_1 have and will maintain wo rkers· compensation insurance, as required by Section 3700 of the Labor Code. for the perfon nance of <br />the work for which this pcm1it is issued. My wo rkers' compensation insurance carrier and poli cy num ber are; <br />Carrier: __________________________ _ <br />Policy Number:. _____________________ Expires: __________ _ <br />_I cert ify that in the performa nce of the work for wh ich this pem1it is issued. I shall not employ any person in any manner <br />so as to become subject lo th e workers' compensation laws of California. and agree that i fl should become subject to the <br />workers' co mpensation provisi ons of Section 3700 of the Labor Code, I shall. forthwith comply with those provis ions. <br />WARNING: Failu re to secure workers' compensation coverage is unlawful, and shall subject an emp~oyer 10 c7rirninal penal · and <br />civil fines up to one hundred thousand dollars ( 00.000), in addi tion to the cost of co mpensation, damages as pro,iid or the <br />Sectio n 3076 of the Labor Code. interest and atto ey·s f~. A . 1 /2, f <br />Date:. _____ A icant: / // 11/J.P AYJ l.V'/ /11~ ' <br />'\ •-_LARATI ON <br />L1 C ll'.NS111 CO NTRA<"TllR ,/j: <br />I hereby affirm under penalty of perjury that I am liccnsc&der provis ion of Chapter 9 (commenci • ith Sect ion 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />Li ce nse Class.: _______________ License Number: _______________ _ <br />Date .: ____________ Contrac tor: _____________________ _ <br />CONSTRUCTI ON LEN DING AGENCY <br />I hereby affirm und er penalty of perjury that there is a construction lending agency for the perfonnance of the work for which this permit is <br />issued (Sec. 3097. Civ. C.). <br />Lender 's Name: _________________________ _ <br />Lender·s Address: _________________________ _ <br />A PPLICANT D EC L ARATION <br />I hereby affinn under penalty o f perjury one of the following declarations: <br />Demolition Permits-Asbestos Notificatio n Federal Regulations (Title 40. Part6) <br />_Req uired Letter o f Notification <br />_I certify that the federal regu lat ions regarding asbestos removal are not applicable to this project. <br />I certify, iat I have read this application and state that the abo ve info nnation is correct:::ZI agree to com ywith all City and County <br />ordi . nc . nd State Laws rela_ting to,t1ildin constni ction. andjj1er a~t. e representatives o fthi . y and Cou1zty o en ter u n the <br />a bove nt1oned prope,ty for tns peclt Op f"]" ) /) /Vt( r fi;; ;: I r (I/ <br />Applicnn1 or ~'\gen1Signatur e: '//J.,,Jv" /// , {JI/J Date: / I~ )/{ ) <br />Pcrmitc~n/4rint):_ /\/() \('I) { Ci ( J'TrriC111 /) 1 r)(J1 ';!) _/"---I '-' ~ -// l -- <br />V