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BUILDING-INSPECTOR RECORD SITE-WORK DATE ID/SIG. COMMENTS OWNER B UILDER DE LCARA TION . I here by a ffi rm und er penalty o f perjury that I am exem pt from the Con1ractors· License Law for the following reason (Sec.703L5 Set Backs Business and Pro fession Code): Any City or County wh ich requires a pcnnit to const ruct. alter, improve. demolish or repair any Forms/Steel/Holdowns structure , prior to its issuance. also requires the ap plica n1 for suc h pennit to file a s ig ned slalemcnt that he or she is licensed pursuant to the provisio ns o f the Cont ractor"s Licensed L1w (Chap1er 9, Commencing wi1h Section 7000 of Div is ion 3 of the Busine~ and Erection Pads Professions Code) or that he or she is exemp t therefr om and the basis for the alleged exemption. Any violat ion of Section 7031 .5 by any :lpplicant fo r a pennit subjects the appl jcant to a civi l penalty o f not more than fi ve hundred dollars ($500). UFER Ground \ _I. as owner of the property. or rn y e mployees with wages as the ir sole compensation. will do the work and the structw·c is not ~ SLAB Floor intended or o ffered for sale {Sec. 7044, Business and Pro fessions Code: The Contractor·s License Law does not apply to an owner of SubfloorNent/lnsulation lhe pro perty who builds or improves thereon . and who does such work himself or herself or through his or her own employees. provided that such impro vements arc not intended or offered for sale. If. hO\~ever, the building or improvement is sold within one year Roof Sheathinq o f co mpletion, the Owner Builder will have the burden of proving that he or s e did not build or improve the propeny for the purpose of sale). Shear Wall _I. as owner of the propmy. am ex clu sive ly contra cting with licensed co ractors to construct the project (Sec. 7044. Business Framino ~ -~-• '"• ~"'-'°'' Uroo" ,,. a,. om ''"'' •• '":\_r""' oOO .,,. "'Omero•«"'"-and who contracts for s\1ch projects with a Contractor(s) lict-nsed pursu to t he Contractor's Lic ense Law). I nsulation/Enerqy _t run exen/~her Sectio n \ . rfor th is re n. Drvwall Da te : f c/j L~ Owner:\ Ext.lint. Lath • '( \V 'H'K F.I Ai:J:IO N ...... '-DE!;;L ARATi'QN Brown Coat I hereby affirm under pe nalty of perjury one of the fo ll owing declarations: Masonrv _I have and wi ll main tain a Certifi cate o fConscnl to Self-Insure fo r workers' compensation. as provided for by Sectio n 3700 of the Po o l Fence Labor Code. fo r th e pcrfonnance o f th e work for whic h the permit is issued. T-Bar _I ha ve and w ill main tain work ers · compensat ion insuranc e, as requ ired by Section 3700 of the Labor Code. for the pe..,-formancc of the work for which this pennit is issued. My workers' compens ati on in surance carrier and policy number are: Handicap Req. Carrier: r Deputy Final Report Policy Nu mber: \ Expi res: Enoin eer Fin al Reoort _I certify that in the performance of the work for which this pcnnit is i ued . I shall not employ any person Ln any manner Flood Zone Certif. so as to beco me subject to the workers' compensation laws ofCalifom ia . .u agree that if l should beco me subject to the workers' compensation provisio ns of Sect io n 3700 of the LaOOr Code. I shal forth with comply with !hose provisions. w""'"' "''"" " = '••~• --~ """'"'· ~ ,~, _.,~ • -•~" """"' ~•"'" .a I civil lines up to on e hund red tho usand do llars {$100.000 in addition to th cost o f compensation. dama ges as prov ided for the Sectio n 3076 o f •;1;bor Code, interest and nttom, v·s FINAL li,f('/ J'J,,., -;_~-1.1.J-Date:' /'2-/ / '/ ( A pplica . ,.. ~ ' Certificate of Occuoancy , . -,.-v1...., I I I ICENSE . . T O R u -- DE!;;LA RATION Notes, Remarks, Etc. I hereby affirm un der penalty o f perjury that J run Iii ~nsed under pmvision o f Chapter 9 (commencing. with Section 7000) of Divisio n 3 of the Business and Professions Code. and my lie !nse is in full fo rce and effect. Lic ense Class: License Number: Date: C ont ractor: C O NSTRUCTION LENDING AG EN!;;Y I hereby affi mt under pena lty of perjury that there is a construction lending agency fo r the per fo n nanc e o f the work for which this pennit is issu ed (Sec. 3097. Civ. C.). Lender's Name: Lender· s Address: { ~rrl 1cANT DE C LARATION I hereby affirm under penall y of perjury one o f the follO\t ng declarnt ions : Demolition Permi ts -A sbestos Notificat ion Federal Reg la1io ns {Title 40. Part6) _Required Lett er o f Noti fication -' =•'''"" .. ,-~"'""" ~ ;--·" ••• , ~, •• ,'" '"" """' _I cert ify that I have read th.is applicat10n cl state that the bo \•C in fonnallon is correct l agree to comply with all City and County ~,o-.a So•o ~~ Oo ~,, _M ,o. • ... , ••·•-•~••--•= oCO~ '""" ="'' <o 000 """'" above ment io ned p1o pc11y for u pcctton pu scs • ~fa.- Applmrnl or Agent Signa h Da te -Z.. - Permilcc na me (print ): , --------......... -