10191331 - Permit - Laserfiche WebLink

Home Browse Search

SITE-WORK Set Backs Forms/Stee l/Holdowns Erecti on Pad s UFER Ground SLAB Floor Subfloor/Vent/lnsulation Roof Sheathina Shear Wall Framinq lnsulation/Enerav Drvwa ll Ext.lint. Lath Brown Coat Maso nrv Pool Fence DATE ID/SIG. BUILDING-INSPECTOR RECORD COMMENTS OWNER llUILDER DF.LCARA TION l hereby affirm under penalty o f 1>erju1y th;it I am exem pt fro m the Contractors· L ice nse Law fo r the fo ll owing reason (Sc c.70 3 1.5 Business and Profession Code): J\ny Cit y or Co unty which req uires a pcm1i1 to conslruc t. alt er. improve. demo lis h or repa ir any s trnclurc. prior 10 its issuance. also requires the ap plicant for such permit lo lile a signed statement tha t he or s he is licensed pursuant to the prnvisio ns of the Cont ractor·s Licensed Law (Chapter 9 . Commencing with Sect ion 7000 o f Divisio n J. o f the B usiness a nd Professions Code) o r th.it he or s he is c.xcmpt there from and t he bas is fo r the a lleged exemption. Any violation ofSec tiOn 70 3 1.) by any applicant for a pcnnit subjects the applica nt to a civil penalty o r not more than fi ve hu ndred doll ars ($500). _I. as owner orthe property. or my employees with wages ns their sole compensat ion. will do 1he work and lhe structure is not intended oroO'ered for sn lc (Scc.7044. Business and Professions Code: The Contracto(s License Law does no1 app ly 10 an owner of the prope11y who builds or im proves thereon. nnd who does such work himself or herself or through his or her own employees. provided th at such improvements are not intended oroITcrcd for sale. If. however. !he build ing or improvement is so ld within one year of completion. the Owne r Builder will have the burden of pro ving that he or she did not build or improve the propcny for the purpose of ,1 sale). _I. as owner of the property. mn C,\:Clusivcly contract ing with licensed contractors to constrnct the project (Sec. 7044. Business and Profession Code: The Contrac1or·s License Law docs no t app ly 10 an owner o f pro pcny who bui lds or improves thereon. and w ho co ntracts for such projects with a Contmctor(s) licensed pursuant to the Contractor's License Law). _I am exemp t under Sect ion ________ • B. & P.C. forthi s reason. D:'1e: __________ Owner:. _______________________ _ WORKERS' C OMPENS ATI ON DECLARA TIO N I hereby affirm un der pena lty of perjury one o f the foll owing declarat ions: _I have and w i ll ma intain a Cc11ificatc of Consent to Self.Insure for wo rkers· compensat ion. as provided for by Section 3700 of the Labo r Code. fo r the pcrfonnance o f the work for which the pem1it i'i issued _I have and w i ll maint ain workers· compe nstll ion insurance. as req uired by Seccion 3700 of the Labo r Code. for the perfon nance of T-Bar the work for which this pennit is issued. My workers· compensat ion insurnnce ca1Tier and po licy number nrc: 1-H..::....a_nd"-'-i..::....ca:....i.10:.._:....:...::...Rea.:L. _____ -+------+---+-------------1" ,,.;." o!dlf~L) G~H .. / I,,~ Deputy Final Report Mcy Numbcr A ~~ JI 1/"(Jtooo E,p;rcs 1 0 ~/-I 7 Enainee r Final Reo o rt Flood Zone Certif. ' _I cert ify thnt in the performance of the work fo r which this permit is issued . I shall not employ a ny person in an y mann er so as to become subjecl 10 the work ers' compensat io n laws of California. and ag ree that if I sho uld become subject to the wo rkers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwi th comply wilh those provisions . ,I"'\ civil fines up to one hund red thousnnd dollnrs ($100,000). in addit i the c st o o snt ion, danmges as pro vided for the /_I Scc1ion 3076 of the Labor Code. interest nnd allorncy·s fees . WARNING: Fail ure to secure workers ' compensation cove~age is unl aw nnd all su ~eel an employer to criminal pena lties ;ind .,__F_IN_A_L ________ __._.,//.._-_~_~_-/i_r\l''---',~Y.J'--=F-.. ./J~lJ_.___ _________ ,,.q,.,1/Date: //-'f-/ {, A ppl;c:mt:==6'==-=c-::=-::-------- Certificate of Occupancy v ....._,, / 1.1cE~~;:i~;·1~~c roR 1-------------..:..--...::-----------------------------------~ I hereby a!Ttrm under penall y o f perjur y that I a 111 licensed under pro vis io n o f Chapter 9 (commenc ing wit h Section 7000) of Division 3 Notes I Remarks I Etc . of the Business and Profess ions Co de. :ind m y license is in fu ll force nod eITcct. \ ' i I lce,~e Class ~ 0 S (, 2-L, Licenre~~ Dat e: //--4-/ {, C untrnctor: ___ ~_,._1<.... _________________ _ CONSTRUCTION LENDING AGENCY I hereby affi rm under penalty of perjury thm there is a constrnct ion lending agency for 1hc performanc e of t he work for which th is permit is issued (Sec. 3097. c;v_ C.). Lender 's Nnmc: __________________________ _ Lender's Address: _________________________ _ APPLICANT DEC LARA TIO N I hereby nninn under penalt y of pc1j ury one of the fo llowing declara tions: Demoli tion Pcrmit s·Asbcstos Notification Federal Regulat ions (Titl e 40. Pan6) _Required Le tt er o f Notification _1 cer11fy th.it the federal regu lat1ons;~cga1d111g as bc tos removal ru e 110 1 appli cable to this proJect _I cc11 1fy lha l I have read this appllcat mn and nt hat th vc mfommt1on 1s correct I agree to comp ly with all City and Coumy ordmanccs and State La,~s relating to bll!,ld11 stni n. and hereby authonze represcnta\lves ofth1s City and Counly to ente r upon the \. ~vc mentio ned property for msp~ _ t----------------------------------------------------ft,v--'Apphc:rn l 01 Agent S 1gn,1t urc r/ /1 D,llc '/ -9,,_ r' 1-----------------------------------------------------,o/'-----1!\Permitee name (print): ___ ,_12,/(_j.i!~.!4,/~1--~-.J/;;,.<,._.,~:.,~{v'.!,!...4/e::.... ________________ _ ✓ Rev. 08-07-2015