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BUILDING-INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG. COMMENTS O W NER BUILDER DE LCARAT IO N ~
<br />I hereby affirm under penally o f perjury that I am e.'<empt fro m the Contractors· License Law for the foll owing reason (Sec.7031.S
<br />Set Bac ks L --/ 116/l,,b /J. nt/1'\-. ~ Busi ness and Profossion Code): Any City or County which requ ires a JX.11ni1 to construct, alter, improve. deu.10 \ish or rcpa;r an y :
<br />Forms/Steel/Hold owns i/· ~, -=c.A -~ / u ___.)
<br />structure. prior to its issuance. also requires th e npplicant fo r such pe rmit to (iJc a signed statement that he or she 1s lice nsed pu rsuant
<br />' to lhe provisions o f the Contractor's Licensed Law (Cha pter 9. Commencing with Section 7000 of Division 3 of the Business and
<br />Erection Pads Professions Code) or th at he or she is exempt therefrom n nd 1hc basis for the alleged exem ption. Any violat io n of Sect io n 703).5 by any
<br />applicant for a permit subjects the applicant to a civil penalty of not more than five hundred doll ars ($500).
<br />UFER Ground _I. as owner of the propc11y. or my employees with wages ns 1heir sole co111pe11snt ion. will do the work and the stn.icturc is not
<br />SL.AB.. Floor -intended or offered for sale (Sec.7044, Business and Professio ns Code: The Cont ra ctor's License Law does not apply to an owner of
<br />pubfloor}'Ve nt/lnsulation 01/03//7 ~ ~o__}
<br />the property who builds or improves thereon. and who does such WOl'k hi mself or herse lf or through his or her own employees.
<br />.Ao) prov ided that such improvements are not intended or offered for sale. If. however. the bu ilding or improvement is so ld within one year
<br />Rbof v;';e athinQ'~hl ~ ~r J r, i
<br />of complclion. the Owner Builder will have the burden of pro,~11g that he or she did no t buil d or improve the property for the purpose of ... n sale).
<br />Shear Wall L,...,-' ~I \.JI' I I/ _j:: rtf-Ll''~ I _I. as owner o f the property. am exclusively contracting with li censed contractors 10 construct the project (Sec. 704 4. Business
<br />Framinq ~ 310 1/<J~ C"l r46/17 A12...tUI---M'ML. and Profession Code: T he Contractor·s License Law does not apply to an owner o f property who builds or impro\'es lhcrcon.
<br />and who cont racts for such projects with a Contractor(s) licensed pursuant to the Contractor·s License Law).
<br />Insulation/Energy I f'a'-i 1 1/./rre~J ~,.1 ,,,,..,,,,,,,
<br />J I/ _I run exempt under Sec tion . 8. & P.C. for this reason.
<br />Drywall 31 "1 ,, 'N'-J ~ ~I -vv /q,~ Ont e: Owner :
<br />Ext/Int. Lath ~ 14 1{1 M !~:,.; \...:.,,"' WQ llKF.R~' !;;OMl'ENSATIQ N
<br />DE(;LARA TIQN
<br />Brow n Coat !. -{0'--17 y. ~jq I hereby affirm under penalty o f perjury one o f the fo llowing decla rations: . -· .J' cfe/o-'tc * J-711-1 1 ~ 't:bJ't ') J~ C, ~ (7~ _I have and w ill maintn.in a Certi ficate o f Consent to Self-Insure fo r \VOrkers· compensation. as provided for by Section 3700 of the ---
<br />Pool Fence --Labor Code. for the perfonnance o f the wo rk for which the pen11it is issued.
<br />T-Bar _I ha,,c and will ma intain wor kers· compcnsa1ion insurance, as required by SL"ttion 3700 of the Labor Cude. for the pt,i·fonnancc of
<br />the wo rk for whic h this pcnnit is issued. My wo rkers· co1npcnsation in surance carrier and policy number are:
<br />Handicap Req. Carrier:
<br />Deputy Final Report Po licy Number: Expires :
<br />Enqineer Final Report _I ccn ify that in the performance of the wor k for which thi s permit is issued. I shall not employ a ny person in any man ner
<br />Flood Z o ne Certif. so as to beco me subjccl to the workers' compcns.ition laws of Californ ia. and a!,\rce that if I should become subject to the
<br />worket·s' compensa tion prov isions of Sect ion 3700 of 1he L1bor C'odc . 1 shall. forthwith comply wit h 1l1osc p1·ovisions.
<br />WARNING: Fai lure to secure workers' compens.ition coverage is unlawful. and sha ll subject an emp loyer to crim ina l pena lt ies and
<br />((\ civil fines up to one hundred thousand do
<br />1
<br />:[~compensm ion, damages as prov ided for the
<br />. Section 3076 or7;Labo r_Codc, (nt erest and atl om 's recs.
<br />FINAL (11-;i.2--1 I )(. \r.JJ,61 Dalee .// J,/fL A1 · 1, /2 1/J/J ~
<br />Certificate of Occupancy V V I :~ LI C E NS ED C •~"n Ar ·roR --
<br />........_ DEC LA RATIO N
<br />Notes , Remark s, Etc. I hereby affirm under penalt y o f pe1jury that) am licensed under provision o f Cha pter 9 (commencing wilh Section 7000) of Div ision 3
<br />or the Business and ProlCSs ions Code. and my license is in full fo rce and effect.
<br />License Class: I 1 ;,,,..,c-,. ~umber:
<br />.1,1/9/41:.. Ctt§ ~ /1 /l A /l Date:
<br />{ ( -
<br />.O NS~'rlON L{NDI NC A;EN:;; l,/ Vt!,/ I
<br />I hereby affirm under penalty o f perjury that ther e is a constniction lending ngcnc y for the pcrfonnance of the work for which this pennit is
<br />issued (Sec. 3097, Civ. C.).
<br />Le nder's Name:
<br />Lender·s Address:
<br />A PP LI CANT DECLARAT ION
<br />I hereby affinn under penalty of perjury one of the fo llowing. declarations:
<br />Demoli1ion Perm it s-Asbestos No tificalion Federa l Regulat io ns (Title 40. Part6)
<br />_Requi red Lener ofNotilication
<br />_I certify that the ft.·ch:ra l regulations regarding asbes1os rem ova l are not ap pl icable to this project.
<br />_I tify t at I have read 1his application and stat e that the above infon nation is co1Tecl. I agree to comply wit h all Ci ty and County
<br />ordinan d State Laws relat ing: to bu ild ing construct ion. and hereby authorize representatives o f th is City and Count y to enter upon the
<br />above me ned property for inspection purposes.
<br />~/2z//t_ Appli cnnl or Ai ti gnaturc : 77:)t' ~ V V Da l e:
<br />Permitcc ; ~ Cf;f)/9,,44
<br />.... ,.. ...,_ ........ ·-,
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