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SITE-WORK Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subfloor/Vent/lnsulation Roof Sheathing Shear Wall Framinq Insulation/Energy Ex(o/1 nt./Lath G/l'Yl> Ir~ '/,AN lbl..f Brown'Coat ' Masonry Pool Fence T-Bar Handicap Req. Deoutv Final Report Engineer Final Report Flood Zone Certif. FINAL Certificate of Occupancy Notes, Remarks Etc. DATE iz. 11 I IJf, ' I r1 17 n </11 J -1r, I I I f V I YI'"/ Lr7 I BUILDING-INSPECTOR RECORD COMMENTS OWNER BUI LDER DELCA RA TION I here by aflinn under penalt y o f perjury th at I am exem pt fro m the Contractors ' License Law for the following reason (Sec. 7031.5 Business and Pro fession Code): Any C ity or County whic h requires a permit to const 111ct. altcr. improve, dcmolis l; or n..--paif an)' structure. prior to its iss uance, also requires t he applicant fo r such pennit to file a signed statement that he or she is licensed purs1;;:ant to the provisions of th e Cont raclor ·s Licensed Law {Chapter 9. Commenc ing with Section 7000 of Div ision 3 o f the Business and Pro fessions Code) or tha t he or she is exempt th erefr om and the basis for the a lleged exemption. Any violat ion of Section 703 1.5 by any a ppli cant fo r a pe nnit subjects l he applica nt to a ci vil penalty of no t more tha n five h undred doll ars ($500). _I. as owner of t he property. o r my e mployees with wages as t heir sole compensation. will do the work and the structure is no t intended or offered fo r sale (Sec. 7044, Business and Professions Code: T he Contractor·s License L-iw does not npply to .in owner of the propeny who bu ilds or improves thereon. and who d oes such work hims e lf or herself o r through his or her own employees. provid ed that such improvements are no t intended o r offered for sale. I( however. the building o r improvement is sold w i1hin o ne year of comp letio n. the Owner Builder "~II have the burden o f proving that he o r she did not build o r improve the property for the purpose of sale). _I. as owner o f the property. run exclusively conlracting with licensed contractors to construct the project (Sec. 704 4. Busines.s and Pro fession Code: T he Contractor's License Law docs not apply to an owner of prope rty who builds or improves thereon. and who contracts fo r s uch projects with a Contractor(s) licensed pursuant to th e Contractor·s License L1w). _I am exempt under Sectio n, ________ • B. & P.C. for t his reason. Date: __________ Own er :. __ ===~--~-=~------------ WORKllRS' COMPENSATION DEC L ARATION I hereby affinn u nder penalty of perjury o ne of the fo llowing declarations: _I have and w ill maintain a Certificate of Consent to Self-Insure for workers· compe ns a tion. as provided for by Section 3700 of the Labor Code. for the perfonnance of the work for which the permit is issued. __Lfliavc and w ill ma intain workers· compensat ion insurance. as required by Sectio n 3700 of the Labor Code. for the perfonnance o f lfie work for which this penn it is issued. My work ers · compensat ion insurance carrie r and policy number are: Carrier:_~ ___ £~d:?l~~le,~&--~VJ~d~------ Policy Nu mber :._~ ___ ')-1-_._I ..._I "7_,__.(:,_. _l-'--''L-=-_______ Expires: _'_)_/_,_/_6_,_/_] __ _ _I certify that in the performance o f the work for which this permit is issued . I s hall not employ any person in any man ne r so as to become subject to the workers' compensation laws o f C alifornia.. and ag ree that ifl should become subject to the wo rkers' co mpensat ion provisions o f Sectio n 3700 of the Labor Cod e. I shall . fort hwith comply with those provisions. W AJlNlNG : Failure to secure wo rkers' co m pensa tio n coverage is unlawfu l. and shall subject an employer to criminal penalties and civil fine s up to one hundred thousand dollars ($100,000). in additio n t o the cost of compensation. damages as provided for the Sect ion 3076 o f the Labor Code. interest and attorney's fees. Date: • l 2 . l:, •I (p Applirnnl: X., ~ --~-~~~---LICENSED CONT RACT O R D EC LARATI ON I hereby a ffirm under penalty of perjury thal I mn li c.:enscd under provision of Chapter 9 (commencing with Seclion 7000) o f Division 3 o f the Business and Pro fessions Cod e. and my lic ense is in fu ll force and cfTcct. Licens e Class: t {2, Da te ' J 2-, 0 ' } G License Number: __ , ___ "\_S_/_/_2._2. _____ _ Contraclor:_'~~--~-e:~;:::..~d@::('.::;~~~~~=====------ CONSTRUCTION LENDI NG AGE NC Y I hereby a ffi rm under penalty of perjury that there is a construction lending agenc y for the perfonnance of t he wo rk for which this pennit is issued (Sec. 3097. Civ. C.). Lend er's Name: _________________________ _ Lender ·s Address: _________________________ _ APPLICA NT DECLARATION I hereby affin n unde r pe nalty of p erjury o ne of the fo llowing declarat ions: Demolitio n Pen nil s-Asbcstos Notificat ion federal Reg u lations {Tille 40. Part6) _Required LcttcrofNotiFicatio n _I certify !hat the federal reg ul ations regarding asbes1os removal are not a pplica ble to t his project. _.:::; ¼ertify that I ha ve read this appli cation and state that the above infonnatio n is correct. I agree to comply with all C ity and County t-----------------------------------------------------1 ordinances and State Laws relat ing to building construction. and hereby authorize representatives of this City and County to enter upon the above mentioned pro perty for inspV ion pu~s~..::? ~ ~ ; ,• 2. 1 1 • I l_ AJ>p li ca nl or Agent Signnture:-#-c=.-~0 -~=-"'=<-------::..--=---=----"' ,r---_________ Da te: _____ ~--~- Permitee na me (prinl): i-. C L,),v(){<._ @'-/ C/1 @(ft.