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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 />Subfloor/Vent/lnsulation
<br />Roof Sheathing
<br />Shear Wall I
<br />Framinq
<br />lnsulation/Enerqy I
<br />Drvwall
<br />Ex t.lint. Lath f
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req . ,
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />I I
<br />FINAL
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />_BUILDING-INSPECTOR RECORD
<br />COMMENTS OWNER BUI LDER D EL CARATION
<br />I hereby affirm under penalt y or perjury that I run exempt from the Contractors· License Law for the following reason (Sec.703!.5
<br />Business and Profession Code): Any City or Cou nty which requ ires a pennit to cons1ruct. alter, improve. demolish or repair any '
<br />structure. prior to its issuance. also requ ires the applicant for such pennil to file a signed statement that he or she is licensee'. pursuant
<br />to the provisions of the Contractor's Licensed Law (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and
<br />Professions Code) or th at he or she is exempt t herefrom and th e basis for the all eged exempt ion. Any violation of Section 703 1.5 by any
<br />appl ica nt for a pcnnit subjects the applicant to a civil penalty of not more than five hundred doll ars ($500). 6
<br />_I. as owner of the propeny, or my employees wi1h wages ac; their sole compensation, will do the work and the stnicture is not
<br />intended or offered fo r sale (Sec.7044. Business and Professions Code: The Contractor's License L,w does not apply to an owner of
<br />the property who bu ilds or improves thereon. and who does such work himself or herse lf or through his or her own employe~
<br />provided that such improvements are no t intended or offered for sale. If. however. the building or improvement is sold ,~thin one year
<br />of comp letion, the Owner Builder will have the burdc;..11 of proving that he or she did nol buikl or improve th e property for the purpose of
<br />sale).
<br />_l. as owner of the property. am exclusively contracting with licensed contractors to constnict the project (Sec. 7044. ,Business
<br />and Profession Code: The Contractor's License Law does not appl y to an owner of property who builds or imp roves I hereon.
<br />and who co ntracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law).
<br />_lam exempt under Section, ________ . B. & P.C. for th is reason.
<br />Date : __________ Own e r : _______________________ _
<br />WORKERS' CO~IPENSA TION
<br />D ECL A RA TION
<br />I hereby afflrm under penalty of perju ry one of th e following declarations:
<br />_I have and will maintain a Certificate of Consent to Self-Insure for workers' compensation. as provided for by Section 3700 o f the
<br />Labor Code, for the perfonnance of th e work for which t he pcnnit is issued.
<br />_I ha ve and will maintain workers· compensation insurance. as requ ired by Section 3700 of the Labor Code, for t he perfonnance of
<br />the work for which this pe11nit is ,issued. M y workers' compensation insurance carri~r and policy ~bcr are:
<br />Carrier 'i" t e, YJCh }tjar JC -~Sv 'f"CW1L e, (__{lvV ~ .
<br />Policy Num ber c 5 r S:-00 -::f 91 f: Expires~U ~//5,/; 7
<br />_1 cenify th at in the perfonnance of the work for whic h this penn it is issued. I shall 1101 employ any person in any manne r
<br />so as to become subject to the worktTs' compensation laws of Cali fomia. and ag ree th at if I shou ld become subjecl to the
<br />workers' compensation provisions of Section 3700 of the Labor Code, I shall , fonhwith comply with those pro visions.
<br />\VAJtN ING: Fail ure to secure wo rkers' compensation coverab~ is un lawfu l. and sha ll subject an employer to crim inal penalt ies and
<br />civi l lines up to one hundred thousand dollars ($100.000). i~l ~ddition to the co.st of compensation. damages as provided for the
<br />Section 3076 of 1hc Labor Code. interest and attorney'\ fc;5.
<br />Date; :!oU✓ it;' -[ l Appli can .. t.:a, X~-'c::\J;J\:-::::=-7==,--------------,f!/J ,;.~NSED ~ NTRACTOR
<br />DEC LARATION
<br />I hereby affinn under penally o f perjury that I run licensed un der provisi on ofChapler 9 (commencing wil h Sec1ion 7000) of Division 3
<br />of the Business and Professions Code, and my license is in full force and effect.
<br />:-,.,,.___,,..,.,<'2 >'7 tfOJa--:1.02"
<br />Li cense Class:~µ.-L_I_>L_·..:::...7~(h=c__----'r-License Number: __ .._/ __ , __ C>---'CJ;;...._'-' ______ _
<br />Contrae10Y J-zry(..-{; I/) <-C,j,_ i} -V 7
<br />CONSTRUCTION LENDI NG AGENCY
<br />I hereby affirm under penally of perjury t hat there is a construction lending agency for the perfonnance of the work for which this pennit is
<br />issued (Sec. 3097, Civ. C.J.
<br />Lender's Name: _________________________ _
<br />Lender·s Address: _________________________ _
<br />APPLICANT DECLARATION
<br />I hereby affinn under penalty of perjury one of the fo llowing declarat ions:
<br />Demo li1ion Permits-Asbestos Notification Federal Regulations (Title 40, Pan6)
<br />_Required Letter of Notificatio n
<br />_I certify that the federal regulations regardi ng asbestos removal are not applicable to this project.
<br />_I cen1fy that I have read tlus apphcauo /'Jnd state t hat the above mfonnauo n 1s correct I agree to comply wuh all Cny and County
<br />ordmanccs and State Laws relat;fng buil d,~}-constru cuon. and hereby authonze representatives o f th1s Cny and County to enter upon the
<br />above mentmned prope1ty for lfl ct1on Ir _ ,r
<br />Applicanlor Agent Signalure ~~ . Da le ,{/C1(; -/[-/£, '7' ,;-: /'·(·
<br />Permitee name (p rint): ,,,,..,,-,· Z6J ,I. Vi l-C(II. { )
<br />C. J
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