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BUILDING-INSPECTOR RECORD SITE-WORK DATE ID/SIG. COMMENTS OWNER HU I LUE ll IJ ELl'A llATIUN . I hereby .i ffin n under pc11nlty of pcijury thnt I run cxempl fro m t he C'ontrnctors· License Lnw for the fo ll owing m1snn (Scc.7031.5 Set Backs Ousi r1css and Profession ('ode): A11y City or Com11y which requires a pcrtnil to co ustrucl . .ihe;.--.·. i111 pro,·e. dc1_nolish or repa'ir any • structure . prio r 10 its iss11n11cc. nlso re<J uires lhe npplirnnl for sui:h pcrmil tn file a s igned stalcment 11ml he cw she.: is lin:ns ed pursuant Forms/Steel/Holdowns to the provis ions o r the C'o nt rnc1or's Licensed Lm,· (rlmp1cr 9. Co1111nenc.:i11g wit!, Sect ion 7000 n f Div isio11 ~ nf 1hc Busin ess anU ...- Erection Pads Professions Code) or thal he or she is exempt therefrom ,md the basis for the nllcgcd exemption. A11y vit1 btion nf Scrtit111 70 ) 1.5 by any .tp plicant for i1 per m it subjt-cts tht": appl ic ;mt to n civil pe1ia lt y o f 1ml n mrc tha n live hundred do ll ars ($500). UFER Ground _i. as owne r o ft he prope11y. or m y cmployct..-s wit h wngL-s as the ir sole compcnsntit'n . will do the \\·Ork rind the structure is 1101 SLAB Floor intended o r o ffered for s.-1le (Scc.7044. B usiness nnd ProfcsslC1ns Code: T he Contrnctor·s License Law docs nm :ipply to m1 cm11cr of the p ro pel1y who builds o r impro,·cs thereon. a11 d who docs such wo rk him self or herself o r through h is o r her (1wn emplo~n·s. Subfloor/Vent/lnsulation --provided that s u ch im pro\'emems arc not intended or o ffered fo r s.1lc. If. howc,·cr. the building o r im pro,·cmc11t is :mid ,, ith i11 llllC year Roof Sheathinq l:>f~/1 ? -uPl\-L .,... #-~ o f rn111pk.1io n. the Owner I3uiklt.;r will h.1Yc the burden u f proving that he or she <lid ll~Jt build o r i111 pn1Ve the pwpC-11) for tht.: pt fflXlSC o f ' . ., --,--,-, sale). Shear Wall I I ~ \JU \:../ _1. as o wner o f the propci1y. am e~clusivcly co11tract ing wit h lic ensed contr:iclo rs lo cuns1ruct the pn1j t.."(I lSeL·. 7(),1 1. B11c:iness Fra ming rmd Pm flX'lKln Code: The C'ontrnc\or's L icense Law docs nol :ipp ly lo nn owne r nf pn~pcrty who bu ilds or imprt'l\'eS !hereon. rmd w ho contrncts for s uch projects wit\1 n Contmctor(s) licensed purs11:i nt to the C onl rncto r's License 1.nw). lnsulation/Ene rav _1 am C.'(em pt under Set:t ion . 0 . & P.C for this f'CilS(l ll. Drywall Date : Owner: Ext.lint. Lath -wuiii,r-:iiS'c-0 ~1,,ENSA Tl(lN -- DEC LARA TI ON Brown Coat I hereby nfli n n 1111dcr pt.·nnlty o f pctjuryone of th e follo wiug dccl:irnl io ns: Ma sonry _I h:we m1d w ill nrni11 1rtin ;-, Ce11ificnte o f Consent to Self-Insure for worker s · co1npens .11 ion. :is prcw idcd fo r by Sc..•1.:l it111 .1700 of the Pool Fence Lnbor Cod e. for the per fonn:incc oft he wor k for which the permit is issued. T-B ar _I have and w ill m aintain workers · com peusnt io n insurnncc. ns required by Scction 3700 of the Lab-Or Code. for t he p1.:IIOnnan cc o f lhc work for w hich this permit is issued. M y wor kers· t:ompc11sa1io11 ins u rance Cilrricl' a nd pulky number nrc: Handicap Req. CatTicr: ' .'.7~7b ~UN'Z> De puty Final Report Po licy Num ber:~/ o/6 S-I' c50 -I b ... 'L?c:>t'?_ Exp ires: Enqineer Final Re port _1 certify th:ll in the performance of the w ork fnr whic h t his pcrmi1 is issued. l s lmll not cmplliy rmy pr r son in any m mmcr Flood Zone Certif. so ns lo become s ubj ec t lo 1hc work ers ' cornpc usalio n la ws ofC'nlifomia . nml agree that if l should become s uhjcct lo the workers' compc11s alion p rovisit1ns o f Sceti'1 n 3700 n f lhc Lalx.1r Cude. I s hall. fm1 hwi1h com ply wi1h thcisc pnwisi(lns, WARNI NG: r-ai lurc to secure \\'orkers' co mpcnsnlion C0\·erngc is unlawful. a nd s hall su~jcc l :111 employer 10 n im inal penalt ies and /'.:\ c iv il fin es up lo one hu ndred tho usand d nllnrs ($100.000). in addi1inn to the cost nf co111pcnsation. d a urng cs as p ro\'idcd fo r the Section 3076 or the Lnbor Code. interL-SI nnd ,mornez -S. FINAL b .... 2-2-17 k .. \LtJ ,;Y 0 ·,· ~ ~ -Dntc: 2 /1,3 /f / Applic,11 ~ ~ Certificate of Occupancy '-"" 1 I c S EU C T R,\CTU II DEC LARATION Notes, Remarks, Etc. I hereby affirm under penalty of perjury t hat I nm li censed u nder provision of C h apter I} {cnmmcnciug with Sect iC'ln 7UUO) C'l f Oivision 3 or 1hc B usiness and Pro fessions ('od e. nnd my license is in fu ll fo rce and cfft!1.:t. - l3, 5~ 2-t5.3 Lic e nse Cl;~ :z:ense Num ber: Onie: zlt.~f-1? Conlrllz 0 1) X }// --t l,;Uf'/ST IIU!,;TIUN LEN DI NG AGENCY I hereby affirm undcr pen.lit )' of pc1jury 1ha1 1here is a c(lnStruct ion lending agenc y for 1hc performance of1hc work fi1r whid, this pcnnit is issued (Sec. 3097. C'iv. C'.). Le nder·s Name: Lcndcr·s Ad dress: Al'l'LIC ANT DEC LARATIO N I ht'lt.--by aflin n under penally of pe1j11 ry o ne or 1he following declrtrnl it,11s : Dem olit io n Per mits -Asbestos Notificat io n Federal Regtllntions (T itle 40. l',1116) _Rt.-q uircd Letter of Notification _I ce11ify thm !he fcdcrnl regulations rcgnrding .lSbt..-sH,s re1mwnl .ire 1ml ri pplicnblc hi th is projcc1. _I cenify that I ha ,·e r ead 1h is .1pplic;1tirn1 and s1nte that 1hc :ibo,·e inform:ttirn1 is con ctt. I agree to rnmply with a ll C it) ;md County ordin;i ncL-s and Sta le Laws rcla ti11g to b11ild i11g co nstructio n. and lu;.·rcby nuthorizc rcpt"cscnla tiv(,'S uft his C ity n11d C\1u11ty Ill t:nler upon the above ment io ned p ro pc11y for insp cc ·o n purposes. -llale:-3/{_? r!tt2 A1i plicantnr ,~gcn1 Signn~ · P<'rmitcc mime (prin t): -------... ,. . -