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SITE-WORK DATE ID/SIG. Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor SubfloorNent/1 nsulation Roof Sheathing Shear Wall IV '-' Framinq Insulation/Energy E xt.JI nt. Lath Brown Coat Ma sonry Pool Fence T-Bar Ha ndicap Req . Deputy Final Report Enoineer Final Report Flood Zone Certif. FINAL Certificate of Occupancy Notes, Remarks, Etc. BUILDING-INSPEC TOR RECORD COMMENTS O WNER BUILDER DELCARATION I hereby affirm under penalty of perjury that I am cxempl from the Contractors' L icense Law for the followiug reason (Sec.7031 .5 Business and Profession Code): Any City or Cou nty which requires a permi t to construct. alter. impro ve. demolish o r repair any stmcturc. prior to its issuance. also requires the appl icant for such pennit to file a signed statement that he o r she is licensed pursuant to the provisions of the Contractor's Li censed Law (Clrnpter 9 , Commencing w ith Sect ion 7000 of Divisio n 3 of the Business .ind Proressions Code) or that he or she is exempt therefrom and the basis for the alleged exemption . Any violation o f Sectio n 7031.5 by a ny applicant for a pennit subjects the applicant 10 a civil penalty of not mo re than five hundred dollars ($500). _I, as owner o flhe propert y, or my employees with wages as their sole compensat io n. wil l do the work and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor·s License Law docs not a pp ly to an o wner or the property who bu ilds or improves thereon. and who does such work himself or herself o r through his or her o wn employees. prov ided that such improvements are not intended o r offered for sale. If. however, the building or improvement is sokt within one year o r completion. the Owner Builder will have the burden of proving that he o r she did not build or improve the pro perty for the pu'l)OSC o f sale). _I. as owner o f the property, run exclusively contracting with licensed contractors to construct the project (Sec. 7044. Bus iness and Profession Code: The Contractor's License Law does not app ly to an owner of property who builds or im pro ves thereo n. and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's LicCnse Law). _1 am exempl under Section, ________ • 8. & P.C. fo r this reason . Da ce.: ___________ Owncr:-::==========o------------- WORKERS' C OM PENSATION OECLARATI ON I hereby a ffirm under penalty of perjury o ne of the fo llowing declaratio ns: _I have and will maintain a Certificate of Consent to Self-Insure for workers· compens ation. as pro vided for by Section 370 0 of the Labor Code, for the performance o f the work for which the pen nit is issued. _I have and will mo intoin workers' compensatio n insurance, ns required by Section 3700 of the Labor Code, fo r the per formance of the work for which this permit is issued. My workers' compensat ion insurance carrier and pol icy number are: Carrier: __ •_-~A __ ·C.._o __ f'_d _________________ _ Policy Numbcr:_• __ (,_00.:...__D_D __ D __ l_>--""---2_..:2 _____ ,Expires; _• __ l _2~/_•_l _2--_o_l _"-_ _1 certifytha1 in the performance o f the work for which this permit is issued. I shall nol employ any perso n in any manner so as to become subject to the workers ' compensation laws of California. and agree that if I should become subject 10 the workers' compensation pro,1isions of Section 3 700 of the Labor Code. I shall. fo11h with comply w ith those p rovisio ns. W A RNING: Fail ure to secure workers' compensation coverage is unlawful. and shall subject an employe r to criminal penalties and civil fin es up to o ne hundred thousand dollars ($100 ,000). in addition to the cost of compensation, damages as provided for the Section 3076 oflhe La bor Code, interest and attorney"s fees. n Date: , { L{ I / z.., (-(, A p p lh:ant, ..,.._ "~ ~ -r LICENSED~N ____IOR ,._ DECLARATION • I hereby amnn under penally of p erjury that 1 am licensed under provis io n o f Chapter 9 (commencing w ith Section 7000 ) of Division 3 of the Business and Professions Code. and my license is in fu ll force and effect. U cense Class: • L -3 ( License Number ; ' C-5 ( -6 S, 2 ~S-/ • ------=---'------ D a I e .. · _ -•-t~L=+/_,_1+...,,z~;;,'-'-'( (;,,_,__ Contraclor ~ l:-\\'5l¼\/\d ('-'~l,,\uCo~( /(""<)+-(Vt r - CONSTRUCTION L EN DING AGENCY I hereby affirm under penalty of pc1jury that there is a construct io n lending agency for the perfonnance o f th e work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name: __________________________ _ Lender's Address: _________________________ _ APPLICANT DECLARATION I hereby affinn under penalty of perjury one o f the following declarat ions: Demolition Permits-Asbestos Notifica1ioll Federal Regulatio ns (T itle 40. Part6) _Required Letter of Notification _I ce11ify that lhe federal regulat ions regarding acibestos removal are no! applicable to th is project. ~ _,J"L;..ceitify that I have read this a pplication and s tate that the above infonnation is correct. I agree to comply w ith a ll City and County i-----------------------------------------------------1 ordinances and State Laws relating to building constmction, and hereby autho rize representatives of th is City and County 10 enter upon the above mentioned p roperty for inspect ion purposes. _.,,,.,----; _ Applicanl orAgcntSigna lure:-,...._ 4 ~ .. ___..,c-.--Dale: • / 2-,/1/ < .:>t.C.. Permitee na me(1lrinl): )(_.,_ .. Tcf£ L tt v-v'\, =