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SITE-WORK
<br />Set Backs
<br />Form s/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subfloor/VenUlnsulati o n
<br />Roof Sheathing
<br />Sh ear W all
<br />Framinq
<br />Insulation/En e rg y
<br />Drvwall
<br />.. Ext.lint. Lath
<br />~wnCoa t
<br />•• _,, ,,.,.
<br />Pool Fen ce
<br />DATE ID/SIG.
<br />I2--Z..-17 ..J ,J ... ('~J""" ~
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<br />BUILDING-INSPECTOR R ECORD
<br />COMMENTS
<br />.
<br />V
<br />OWNER BUI LDER DllLCARATION
<br />I hereby affirm under penalty of perjury that I am exempt from the Contractors· License Law for t he following r eason (Sec.7031.5 ,
<br />Business and Profession Code): Any City o r County which requires a permit to construct. a lter. improve. demolish or repair any
<br />structure. prio r to its issuance, a lso requires the applicant for su ch pennit to file a signed statement that he or she is licensed 9ursuant
<br />to the provisions of the Contractor's Licensed Law (Chapter 9 , Commencing w ith Section 7000 of Division 3 of the Business and
<br />Professions Code) or that he or she is exempt therefrom and the basis fo r the all eged ex emption. Any vio lation of Section 703 1.5 by any
<br />applicant for a pcnnit subjects th e applicant to a civil penalty of no t more than five hundred dollars {$500).
<br />_I. as owner of th e prope11y. or my employees wit h wages as their sole compensation, will do the work and the structure is not
<br />intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply 10 an owner of
<br />the property who builds or improves thereon. and who docs such work himself or herself or through his or her own employees.
<br />provided that such improvements are not intended or offered for sale. If. however, the building or improvement is sold within o ne year
<br />of completion. the Owner Builder will have the burden o f proving that he or she did not build or improve the property for the purpose of
<br />sale).
<br />_I, as owner of the property. am exclusively co ntracting with lic ensed contractors to construct the project {Sec. 7044. Business
<br />and Profession Code: The Contractor's License Law does not apply to an owner ofprope11y who builds or improves 1hereon,
<br />and who contracts for such projects with a Conlractor(s) licensed pursuant to the Contractor's Li cense Law).
<br />_I run exempt under Section, ________ • 8. & P.C. for this reason.
<br />Da te: __________ Owner: _______________________ _
<br />WORKERS' COMPENSA TION
<br />DEC LARATI ON
<br />I hereby affirm under penalty of perjury one of the fol lowing declarat ions:
<br />_I have and will maintain a Certificate o f Consent to Seir-lnsure for workers' compensation. as provided for by Sectio n 3700 of the
<br />Labor Code. for the performnnce of the work ror which the peimit is issued.
<br />T B _I have and will maintain workers· compensation insurance. as required by Section 3700 of1he Labor Code. for the perfonnance of
<br />H~n:ca p Re q. \ J:~::k r;;hir.:;;/;+; iss2;;;;~f;;~e;;;~ i];=cr and poli cy number are:
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<br />Engin eer Fin a l Re port
<br />_I certify that in the performance o f the work for which this permit is issued. I shall not employ any person in any manner ./
<br />Flood Zone Ce rtif.
<br />workers' com pensation provisions of Section 3700 of the Labor e. I shall, nhwith comply with those provisions.
<br />so as to become subject to the workers' compensata1on laws of Califom· ree that if I should become subject to the
<br />\VARNlNG: Failure to secure workers' com pensation cov ge is un lawfi and shall subject an employer to criminal penalties and
<br />civil fines up to one hundred thousand dollars ($1 00 0). in additio n :zhe cost ompensation. damages as provided for the
<br />Section 3076 of t he Labor Code. in terest and attome fees.
<br />t-F_I_N_A_L ________ ><;_-..::;.~..;..9_-L...!... l?...1..~;;_;,_,1;_.,_J_~___,J.,;_'1'.;,.:Y)::,..__ _______ .,,>{o.,., J:1 ~) t; -16 AppJ~;~~/-·~==1!."_;:!,£~-~:__ __ _
<br />Certificate of Occupancy / u rn~~~L~~;.~NcrnR
<br />Notes, Re marks' Etc. I hereby affirm under penahyof perjury 1ha1 I am licensed under provision of Chapter 9 {commencing with Sectio n 7000) of Division 3
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<br />/
<br />CO NSTRUCTION LENDING AG ENCY
<br />I hereby affirm under penalty of perjury that there is a construction le nding agency for the perfonnance of the work for which this permit is
<br />issued (Sec. 3097. Ch•. C.).
<br />Lender's Name: _________________________ _
<br />Lender's Address: _________________________ _
<br />A PPLICANT DECLARATION
<br />I hereby affin n under penalty o f perjury one of the following dec larations:
<br />Demoli tion Permits-Asbestos Notifica1ion Federal Regulations (Title 40, Part6)
<br />_I certify that the federa gulations regardin asbeslos removal arc not applicable to this project
<br />ordinances and State ws relati ng to building nstructio n eby authorize representat ives of this C ity and County to enter upon the
<br />_Re quired Lc~tcrofNotification
<br />~I cenify that I ha ve · d this applicatio n and te t~r,at the ve, infonnation is correct. I agree to comply w it h all City and County
<br />, above mentioned p perty for inspection p scs. \),-} I') I.
<br />t-------------------------------------------------------lll_,,,.1-,_,.Applicant or Agent ~,g .... ,urc: ' .::..--/'--Dntc: o-/S--6
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