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BUILDING-INSPECTOR RECORD SITE-WORK DATE ID/SIG. COMMENTS O WNER llUI L DE R D E LCARAT ION I hereby affirm under penalty of perjury th at I run exempt from the Contractors· License Law for the following r.:aso n (Scc.7031.5 Set Backs Business and Profession Code): Any City or County whi ch requires a penn it to construct. alter. improve. demolish or repair any structure. prior to its issuance, also requires the ap plicant for s uc h pennit to fi le a signed statement t hat he or she is licensed pursuant Forms/Steel/Holdowns to the provisio ns of the Contractor's Licensed Law (Chap1er 9. Commencing with Sect ion 7000 o f Divisio n 3 of the Bus ittt:ss and Erection Pads Professions Cod e) or that he or she is exempt th erefrom and the basis for the al leged exempt ion. A11y violation of Section 703 1.5 by any applicant for a pc11nit s u bjects the app lic<mt to a c ivil penalty o f no t more than fi ve hundred dollars ($500). UFER Ground _1, as owner of the propeny. or my employees with wages as their sole compensation, will do the work and the stmctLu·e lS not SLAB Floo r intended or o ffered for sale (Sec. 7044. Business and Professions Code: T h e Contractor's License La w does not apply to an owner o f 1he property who builds or improves thereon. and who does such work himself or herself o r through his or her own employees. Su bfloor/V enUI nsu lation provided th at such improvements are not intended or offered for sale. If. however. the building or improvemem is sold within o ne year Roof Sheathinq o f completion, the Owner Builder wit\ have th e burden of proving that he or she d id not build or impl'ovc the propeny for the p urpose o f sale}. Shear Wall _I. as owner of the property, am exclus ively contract ing wit h licensed contractors to constnict the prnjcct (Sec. 7044 . Business Framinq and Profess ion Code: T he Contractor·s License Law does nol apply to an owner of property who builds or improves th ereon. and who con trncts for such proj ects with a Contractor(s) licensed p ursuant to 1he Contractor's License La w). lnsulation /Ene rav _I run exempt ur1der Sect ion . B. & P.C. for this reason. Dryw a ll Date: O w ner : Ext.lint. Lath WOR KERS' CO MPE NSATIO N DEC L A RA TION Brown Coat I hereby affirm under penalty of perjury one of the follow ing declarations: Masonry _1 have and will ma intain a Certificate of Consent to Self.I nsure for workers' compensat ion, as provided fo r by Section 3700 o f the Pool Fence Labor Code, for the pcrfonnance of the work for which the permit lS issued. T -Bar _1 have and will maintain workers· compensat ion insurance. as required by Sect ion 3700 oflhe Labor Code. for the perfonnance of the work for which this pen n it is issued. My workers· compensation ins urance canier and policy number ru-e: Ha ndi cap Req. Canier: Deputy Final Report Policy Number: Ex pires: Enqinee r Final Repo rt _I certify that in t he performance of the work for which this permit is iss ued, I s hall not employ any person in any manner Flood Zone Certif. so as to become subject to the workers' compensation laws of Cali fornia. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of1h e Labor Code. I shall . forthwith comply with those provisions. WAR NING: Failure to secure workers' compensation coverage is unlawful. and shall subject an employer to criminal penalt ies and ci\•il fines up to one hundred thousand doll ars ($100,000}. in addition to the cost of compensat ion. damages as provided for the Section 3076 of the Labor Code, interest and attorney's fees. FINAL /7.-3-/H 10c'Z...."") Date: Applican t: Certificate of Occupancy LICENSED C ONTRACTOR D ECLARATION Notes, Remarks, Etc. I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Sectio n 7000) of Division 3 of the Business and Professions Code . and my license is in full force and efTecl. License Class: License Number: D n t c: C ontrnct or : C O NST RUCT ION LENDIN G A GENCY I hereby affinn under penalty of perjury that there is a construction lending agency for the performanc e o f the work for which this pennit is issued (Sec. 3097, Civ. C.). Lender's Name: Lender· s Address: A PPLIC A NT D ECL ARA T ION I hereby affin n under penalty of perjury on e of the following declarations: Demolition Pennits-Asbestos Notificat ion Federal Regulalions (Title 40, Part6) _Requ ired Lette r o r Notificat io n _I certify that the federal regulat ions regarding asbestos removal arc not applicable to this project. _, _;,,,"• ',_,_, ,_, •w""'" ~-~•"'''""'''"'"'""~""' ordinances and State Laws rela_ti~t~uilding cons ct ion. d hereb ·, uthorize pr entativ of this City and Count y to entcT upon the above mentioned property for ms on purpos . A p pl.ica nt o r Agent Sig nature: ..--· . ~ L7 O:tte: -/ 1 -f -/' P ermitee n:ime (prinl): c'?ir .\ l5l ,{ -;_/ ... -,...._ ........ -