10190535 - Permit - Laserfiche WebLink

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SITE-WORK DATE ID/SIG. Set Backs Forms/Steel/Holdowns Erection Pad s UFER Ground SLAB Floor Subfloor/Vent/lnsulation Roof Sheathing Shear Wall Framinq Insulation/Energy Drvwall Ext.l int. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req . Deputy Final Report Enqineer Final Report Flood Zone Certif. FINAL Certificate of Occupancy Notes, Remarks , Etc . BUILDING-INSPECTOR RECORD COMMENTS OWNER UU IU>E R IJ ELCARATION I hereby affirm un der pe nalt y o f pc1jury 1hm I am exempt from the Con1rac1011i License Law fo r 1hc follow ing reason (Scc.7031.5 Business and Profession Code): Any C'il y or Coun ty whic h requires a pcnnit to constmct. a lter. improve. demolis h or repair ;my stniclllre. prio r to its issuance. ;11s0 requires the nppli cant fo r such permit 10 fi le a s igned sta teme nt tlml he or she i.c; licensed p ursuant to the provisions o f the Cont ractor's Licensed Law (Chapter 9. Comm encing with Section 7000 of Di vision 3 ., .. f tl1e Business an d Profess io ns Code) or that he or she is exempt therefrom and the basis fo r th e alleg.cd exemption. Any vio lal ion o f Section 7m l .. ~-½y any applicant for a pennil subjects the applicant to a civil pen.i.lty of not more th an fi ve hundred doll ars ($500}. _I. as owner oft he property. or my employees with wnges as their sole compensa1ion, wil l do the wo rk ,·md the struct ure is not int ended or offered for sale (Sa:. 7044. Bu siness nn d Profess io ns Code: The Cont ra ctor"s License Law does not apply to an owner of the pro pci1y who bui ld,; or improves thereo n. and who does such work hims e lf or herself or t hrough hi s or her own employe~. provided that such improvements are not imended or offered for sale. If. however. the bu ild ing or i1nproveme nt is sokl wit hin one year of complet ion. the Owner Builder will have the burden of proving th.it he or she d id not build or improve 1he proj)Cl1y for the p11rµoscof • sale), _I. as owner of the propeny. am c:..;:cl us i\·cly contrn cling with licensed conl ract ors to conslruct the project (Sec. 704<1. Business and Pro fession Code: The Contract or's Lice11se La w does 11ot apply to an owner ofprnpcr1y who builds or impro,·cs thereon. a nd who con1rncts for suc h projects with a Co111rac101~s) licensed purs11at11 to th e ('ontrr1c1or·s License Lnw ). _1 mn exemp t un der Section ________ • R & P.C. for this reason. D 1Hc: __________ Owner: _______________________ _ WORKlcRS' CO~I PENSATION llECL A RATION I hereby affirm under penalt y of perjury one of the fo llowing declar ations: _1 have and will main ta in a Certificate ofC011scnt to Sclf•lns ure fo r workers· co mpensat io n. as provid ed for by Sect io n .HOO of the Labor Code. for the perfonnance of the work for whi ch the pennit is issued. _I ha ve anti will maint ain workers' compensation ins urance. as requi red by Sec1 ion 3700 of th e L1bor Code. for the performa nce of the work for wh ich this pennit is iss ued. My workers· compensation insu ra nce cmTier and po lic y number .i re : Carrier ~,. "l'!::-(oN 1~'r ~Hl) \)~ Policy Num ber: ~ 0 \ ~? " l\ ~ I!:; ::;'\JJ'IO ~xpir••= -~-l-=zC.L., _,__J_,-"',b- _I ce1tify 1hat in the performance of the work fo r wh ich this permit is issued . I slm.11 no t employ any person in an y rn a1111er so as to become subject to the workers' compensation laws of Califomin. and agree that i fl should become subjccl to the workers' compensat io n provisions of Sect ion 3700 of the Labor Code. I shal l. fort hwith comply with those pnwisi(l llS. WARNING: Failure to secure workers' compensation covcrnge is unlawfu l. and shall subject an employer to crim inal penalties and civil liucs up 10 11 ,onc hundred thousand dollars ($!00.000). in ndd it ion 10 the cost of compcnsr11ion, damages as provit.l cd for the Section 3076 oftl • Labo,Codc, interest and attomcy·s ~fees. n \f\. . IJ ale: q \ "2 / / l,. A p1>lica11t: ~ ~ ~ """--"' "I-'-' U C •NS)m C O NTllACTOll IJEC LA RATION I hereby amrm under penally of perjury tha t I am li censed 1111der provision o f Chapter 9 (comme11cii1g wi1h Sect ion 700 0) of Div ision 3 o f the l3 usin ess an d Pro fessions Code. an d my lic ense is in run force and effect. CONSTRUC TION LENIJING AGENCY I he reby affirm m1dcr penalt y o f pc1jury t hat there is a constrnctio n lending agency fo r the perfon nnm:e of t he wo rk for which this permit i.,; iss ued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lend cr ·s Address: _________________________ _ A PPLICANT llECLARATION I hereby affi1111 under penalty of perj ury one o f the following dcclarn tions : Demoli 1ion Permits-Asbestos Noti ficat io n Federal Regu!Jl ions (Til le 40. Par16) _Required Le11erofNotificnt ion _I ce11ify t hat the federal regulations regardin g asbestos removal are not a ppli cnble to this proj ect. _I certify that I have read th1s app\1ca11011 and state 1hn.1 the nbo\e 111 fonnnt1on 1s correct I rig.ice 10 com1>ly w11h nil City .ind County oidmanccs and State Laws relating to bu1ld1ng. cons1mc11011. and hereby autho1 1 e reprcscntat1vcs oftlus City an d~\u1nty:1 1e11ter upo n the above mc ntJoncd prope11y for ms~t17 n ~cs. Applirant orAgcnt S ignalu1 c ~ ~....,,,._, ~~",;__;::., Oal c ~ lZ )-1, t--------------------------------------------------~ Permilee11a111e (pri111): __ ~ __ cc:f'--'~'-'\S_\.c.>--_L-'--_M __ 0_'(1 __ ~_1V __ () ______________ _