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INSPECTOR RECORD n _ _ ._ BU.,.I LDING-,-------------------.-------,---;,;-;a..,....;.,..,...,------------------....---------------------------,----------------,-SITE WORK DATE ID/SIG.• COMMENTS OWNER BUILDERDELCARATION ~ • ' I hereby a ffirm under penalty ofperju1)' thnt I am e,'[empl fro m the Contractors· License Law for 1he fo llow ing reason (S,rc.703 1.5 •
<br />Set Backs Business and Pro ressio n Code): Any Cit y or County which requires a pennit to construct. alter. improve. demo lish or repair any
<br />structu re, prior to its issuance, also requ ires lhe applicant for such pennit to file a signed statement that he Or she is \i c;cnss-d pursuanl Forms/Steel /Holdowns to the provisions o f the Contractor·s Licensed Law (Chapter 9. Commenc ing with Section 7000 of D iv isio n 3 of 1he Business a nd ◄
<br />Erect.IQ n Pads Professions Code) or that he or she is C."<C111pl therefrom and th e basis for the al leged exemptio n. Any ,1iol,nion of Section 703 1.5 by any
<br />t-U:-:-F=E=R=--G=-r-o_u_n_d--,------------1-------+--------1--------------------,,J'•~~~ant for a pennit subjec1s the applicant to a civil penalty of not more than five hun dred dollars ($500).
<br />l--------------------1--------1-------I------------------.J ~:,r(;t---:=e' f l. as own er o f the prope11y. or my employees with wages as their sole compensation. will do the work and the s1ructw·e i.c; not SLAB Floor / intended or offered for sale (Sec.7044. Business mid Professions Code: The Con tract or·s Li ce nse Law does 1\01 ripp ly lo an owner of
<br />the propeity who builds or improves thereon. and who does such work him self or herse lf or through his or her own e mployees.
<br />Subfloor/Vent/1 nsu lation provided that such im proYcmenlS are not intended or offered for s.,le. If. howe ver. the building or improvement is sold wit hin on1,year
<br />of completion. the Owner Builder will have the burden of pro ving thrit he or she did not build or impro\'e th e pro pei1y for the purpose of
<br />Roof Sheathinq sale). •
<br />Shear Wall
<br />FraminQ /-7 /;-z,J It. ll~ (,In
<br />_I. as owner oft he property. am exclusively contracting wi th licensed comrnctors to conslrnct the project (Sec. 7044. Busi nc~
<br />and ProfessKln Code: The Contrac1or's License Law does not nppl y lo an owner of propert y who builds or improves thereon.
<br />and who comracts for such projects with a Contrnc101{s) licensed pursuant to the Contrnctor·s License Law).
<br />lnsulation/Enerqy 1 1 ,, -I LJ
<br />1--D_r.,,__vw_a_ll _________ -+_,. \.+\,;_,__\.,_1_7'---'~~:;,.=....,.r"-._..\....CC p(J,(.,___1-'v\P:.___'\ u _ _,,,Llll'1'------'-~.C,,\' ~"-------.I'.'( Dnl~ru; )~";';~er ;«;;'-6 -~;(~\\+-r:-~-·· ,B#~~n.
<br />Ext.II nt. Lath \ l . ·~w°=o~R~K=cF,RccS~' cc,-,0~~~1r=ENSAn~NS~A~itr"'"N~---------
<br />DEC L A RA TION Brown Coat I hereby affirm under penally of pt.."l'juryone oflhe fo llowing declarations:
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />_I ha ve and will main tain a Cc11 ificate of Consent to Self.Insure for \VO l'kers · co mpensation. as provided for by Section 3700 of the
<br />La bor Code. for 1he pcrfomrnncc of the work for which the pcnni t is issued.
<br />_I have and w ill ma inta in workers· compensation insurance. as requi red by Sect ion 3700 of the Labor Code. for the p,,·fonnancc of
<br />the work for whic h this pt.."llnit is issued. My workc.i·s· compensation insurance cafficr and polic y num ber arc:
<br />Handicap Req . Carrier: ___________________________ _
<br />Deputy Final Report PolicyNumber: _________________ ,E,pires: _______ _
<br />rE::-n_g.,__i_n_e_e_r_F_i n--,-a_l_R_e..Ji pL-,o_rt....:._ _____ +-------tf------l-------------------4<1~cr;;~:l..!.· f1..1cert ify that in the performance of the work for wh ich this pennil is issued. I shall not employ any person in any manner Flood Zone Ce rtif . / so as to become subject to the workers· compensation laws of Cali fornia. mid ngree that if I should become subject 10 t he
<br />t----------------------<--------+-------1--------------------' workers' compensation provisions of Section 3700 of the Labor Code. I shal l. fo1thw ith comply with those prov isions.
<br />WA RNING: Failure to secure workers' compcnsa1 ion coverage is unlawful. and sh all subject an employer 10 crimi nal pt"!ialtics and
<br />I / civil fmcs up 10 o ne hundred th ousand dollars ($100,000), in addition to the cost of compensation . damages as pro \·ided for the
<br />t-:F=I N:-:-A-:--:L----,o--/,f-,-:-,--.iqr--ff.'/,'Q7":"---,,././.,.,.,/,.---_,f-:1,(/,.,,...---, //,......,,/.r-: /--t-------+------------------>,t'" _section 3076 o[the Labor Code. interest and attorney"s recs.
<br />1-------=v--+,__/-"-+/"-' j{,. ~,.___--'1':........i.,: L./'--'1.:1-, mL-.;;....._..:....I C/ .......... '1'_...i..,_ __ _._ ________ ~/,..;; Date: II-0 t&-:;Jo /i, ~ca nt:_&-=-::__ A---'~=a =~-=--, _:..__ _____ _
<br />Cert·1t·1cate o·kOc·,r.·upanc•u 7 \ u rnNsED c o N~ II ,1.,1 , J DECLAIIATION Notes , Remarks, Etc. I hereby affirm un der penally of pe1j ury thnt I mn licensed under provision ofChnpl(.T 9 (commencing with Sectio n 7000) of Division 3
<br />of 1hc Business and Pro fess ions Code. and rny license is in fu ll force .1nd efTcc t.
<br />License Class: ______________ ,Liccnsc Number: _______________ _
<br />D11te: ____________ Contrnctor: _____________________ _
<br />C ONS TRUCTION LENDING AGENCY
<br />l hereby affirm under pena lty o f pe1jury that there is a construction lending agency for lhc perfonmlnce of the work for which lhis permit is
<br />issued (Sec. 3097. Civ. C.).
<br />Lender 's Name: _________________________ _
<br />Lender's Address: _________________________ _
<br />A PPLICANT llECLAIIA T ION
<br />I hereby affinn under penalty of perjury one of the fo llowin g declaratio ns:
<br />Demolition Pcrmits•A sbcstos Notification f edera l Rcg ula1 io ns (Ti tle 40. Pm16)
<br />_Required Letter of Notifi cation
<br />_1 cei1 ify that the federa l regulations regard ing asbestos remo val are 1101 llpplicable to th is project.
<br />) ..ii} certify that I ha ve read this applicalion and state that th e above infonnati on is cmTect. I agree to comply with all City and County
<br />1---------------------------------------------------.:_J • ordmanccs and State Laws relat ing to building constrnction. and hereby authorize representatives of th is City nnd Co un ty to enter upon the
<br />above men tio ned propeny for inspecc uJ'.:? ~I / / -0 7 -~/) / iJ,
<br />,-----------------------------------------------------.,)::-lb Applicant or Age ut Siguature: -:J7 ./"'lj·
<br />1
<br />)(Dalc: ________ _
<br />1------------------------------------------------L.../'..J\.'-Pe rmitee nnme(print): & lacft; 9 {!)~/.i?eZ.. I'
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