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BUILDING-INSPECTOR RECORD SITE-WORK DATE ID/SIG. COMMENTS OWNER B UILDE R D ELCA RAT ION ' I hereby affirm under penalty of perjury that I run exempt from the Contractors· License Law for the following reason (Sec.703 1.5 Set Backs Business and Profession Code): Any City or County which requires a pe nnit to construct. alter. improve. demolish or repair any Forms/Steel/Holdowns structure, prior to its issuance, also requires the applicant for such penni1 to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor's Licensed Law (Chapter 9 . Commencing w ith Section 7000 of Divis ion 3 of the 13usincss and- Erection Pads Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. An y violation o f Sect ion 7031 .5 by any applicant for a pcnnit subjects the applicant to a civ il penalty of not more t han five hundred dollars ($500). UFER Ground _I. as owner of the property. or my employees with wages as their so le compensation. will do the work and the structw·e is not SLAB Floor intended or ofTered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law docs not apply to an owner of Subfloor/Vent/1 nsulation the property who builds or improves thereon. and who does such work himselr or herself or through his or her own employees. /"\, provided that such improvements are not intended or offered for sale. lf. however. the build ing or improvement is sold within one year Roof Sheathinq l.'l ·1( ✓\li i-\ \ ,, S-rA,1 >/1{lf;/ of completion. the Owner Builder will have the burden of proving that he or she did not build or improve the propeny for the purpose o f sale). Shear Wall '-./ _I, as owner of the property. am exclusively contracting with licensed contractors to construe! the project (Sec. 7044. Business Framinq and Profession Code: The Cont ractor's L ic ense Law does not apply to an owner of pro perty who builds or improves thereon. and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). lnsu lation/Enerav _I am exempt under Section . 8. & P.C. for this reason. Drvwall D111 e : Owner: Ext.tint. Lath \VQ l!KE RS' !:;OM PENSA TION DECLARATIO N Brown Coat I hereby affinn under penalty of perjury one of th e following declarations: Masonrv _I have and will maintain a Cenificate of Consent to Self-Insure for workers' compensation, as provided for by Section 3700 of the Pool Fence Labor Code. for the perfonnance of the work for which the pennit is issued. T-Bar _I have a nd will maintain wo rkers· compensation insurance. as required. by Section 3700 of the Labor Code. for the performance of the work for whic h this permil is issued. My workers' compensation insurance carrier and policy number nre: Handicao Rea. ,. CG\.J ~()fl\ i °' ~f\S\l'{oi. l'\C e. Com~O,\'\~ Carrier: Deoutv Final Report Policy Number: . :1 to '.:0 ~c, ~ l(i 11 o I Expires: . ~ I ,3 l 1-011 Enqineer Final Reoort _I cert ify that in the performance of1hc work for which this permit is issued, I shall not employ any person in any manner Flood Zone Cert if. so as 10 become subjecl to the workers' compensation laws of Cal ifornia. and agree that if! should become subjccl to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. fmthwith c omply with those provisions. WARNING: Failure to secure workers' compensation coverage is unlawful. and shall subject an employer to criminal penalties and I civil fines up to one hundred thousand d ollars ($IO0.000). in addit ion to the cost of compensation. damages as provided for the t Section 3076 of the Labor Code. interest and attorney's fees . A\-l',(,\S ·\y-J A el t ()}~1uv,J; ?; FINAL 7 //7//7 W4'f I l/9) Date: • \ 1-<ts -Iv Appli cant: "'--- Certificate of Occupancy I -Ll!:;llNSED !:;ONTRACT O R v - DECLARATION Notes, Remarks , Etc . I hel'eby affirm under penalty of perjury that I run liccnSc..."d under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. c-~9 ~5Y~is /} ., 0 --~(Yy1L.-'\7ta'L <.,,(_ l ,f1 ( "__,/( License Class: • Licerrrr: • z3-I .. I' . .,, ,.,... l'Z-.A l t . ,'2..-l.f zz ,.. t ... Date: C ontract o r :)(.., ~ 7 '" /}. ~ ___..., -. ~ -!:;O N§TR!K TION L ~N DIN!:, aGEN!:;Y I 'I>-V I hereby aflinn under pena lty of perjury that there is a construction lending agency for th e perfonnance of the \VOrk for which this permit is Lvt,L, Pr .(/,~hrl~ issued (Sec. 3097. Civ. C.). Lender's Name: . . ' Lender·s Address: A PPLI CANT DECL AR ATION I hmf,y affirm under penalt y o f pe1jury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40. Pa116) _Required Letter o f Notification _I certify that 1he federal regulations regarding asbestos removal are not applicab le to this p roject. /. ~ ~I cc,1ify that I have read this application and state that the alxlve infonnation is correct. I agree to comply with all City a nd County ordinances and State Laws relating to building constmction. and h ereby authorize representatives of this C ity and County 10 enter upon the above mentioned propeny for inspection r::ri;t_,11,£1 ~ 3 -I '?? Applicant o r Agent S ign a ture: ~ , Da le: ,, 12- Permitec name (prifll): ~ Alf'll,'S \YvAC\ \ -------. -