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BUI L DIN G-IN SPECTO R RE CO RD SITE-WORK DATE ID/S IG. COMMENTS OWNER BU ILDER DELCARATIO N I hereby affirm under penalty of perjury that I am exempt from the Contractors· License Law for the following reason (Sec.7031 .5 Set Backs Business and Profession Code): Any City or Cou nty which requires a peimit 10 construct. alter. improve. demolish or repair any structure. prior to its issuance. also requires the appl icant for such pem1 it to fil e a signed statement that he or s he is licensed pursuant Forms/Steel/Ho ld owns to the provisions o f the Contractor's Licensed La w (Chapter 9. Commencing w ith Section 7000 of Division 3 of the Business and Erecti o n Pads Professions Code) or t hat he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031 .5 by any applicant for a pem1it subjects the appli cant to a civil pen ally o r not more than five hundred dollars ($500). UFER Grou n d _I. as owner of the property, or my employees with wages as their sole compensatio n. will do the work and the structure is not S LA B Fl oor intended or orfered for sale (Sec.7044, Business and Professions Code: The Contractor·s License Law docs not apply to an owner of the property who builds or improves thereon, and who does such work himself or herself or through his or her own emplo yees. Su bfl oo r/Ve nt/lnsul ati o n provided that such improvements are not intended or orfered for sale. If. however. the building or improvement is sold within one year Roof Sheathi nQ o f completion. the Owner Builder will have the burden of proving that he or she did no t build or improve the property for th e purpose of sale). Shear Wall _I. as owner of the property. run ex.elusively contracting with li censed contractors to construct the project {Sec. 7044. Business Fra minq and Profession Code: The Contractor·s License Law does not apply to an owner of property who bu ilds o r improves thereon. and who contracts for such projects with a Contractor(s) licensed pursuant to the Contractor's License Law). Insul ati o n/En e rgy _I am exempt under Section . B. & P .C. for this reason. Drywa ll Date: Owner: Ext.lint. Lath WQRKERS' !;;OM PENSA TIQN DE !;;LARAT IO N Brown Coat I hereby affirm under penalty of perj ury one of t he following declarat ions: Maso nry ~' have and w ill maintain a Certificate of Consent to Self-Insure for workers' compensation. as provided for by Section 3700 of the Poo l Fe nce Labor Code, for the perfonnancc o r the work for which the pcnnil is issued. T-Ba r _I have and will maintain workers' compensation insurance. as required by Sect ion 3700 of the Labor Code. for the pcrfonnance of the work for which this pennit is issued. My workers· compensation insurance carrier and policy number are: Ha ndica p Req. Carrier: . Aco<o. De pu ty Fin a l Repo rt . /<Daooo (322-. ,'"2.i I I Z-1:>U; Po licy Number: Expires: En g in eer Fin a l Re po rt _I ce11ify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner Fl ood Z one Ce rtif. so as to become subject to the workers' compensation laws of California. and agree that ifl should become subject to t he workers' compensation provisions of Section 3700 of the LaOOr Code. I shall. forthwith comply with those provisions. \VARNlNG: Fai lure to secure workers' compensation coverag e is unlawful. and shall subject an employer 10 criminal penalties a nd c ivil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as provided for the -I .,... I, Section 3076 of the Labor Code. interest and attomey·s fees . - F IN AL ~-r -16 ..J/~J~-, iz'("Yv/ . I '2.-! ! / Applicant:')(. ~ --::2-Date: I{,. Certificat e of Occupancy I LIC E NSE~~ I DE!;;LARATIQN -I Notes, Remark s, Etc . I hereby affinn under penalty of perjury that I am lic ensed under provision o f Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code. ru1d my license is in full force ru1d cffcc1. (_ -s1 c::-"3 i -65? S-S-1 -License C lass: I License Number: .,. l>atc: • r2.ft1Z::>/t:, Contract o r : )(.,, Hr,ti /qvid G~1:14.e.cc.[0 ~<>1frt /I " !,;01:!!STR!l!;;TIQC!i !,gNDING 1H,EN!;;Y 1 hereby affirm under penalty of perjury that there is a constmction lending agency for the perfonnance of the work for which this permit is issued (Sec. 3097, Civ. C.). Leudcr·s Name: Lender's Address: APPLICANT DECLARATION I herebyaffinn under penalty o f perjury o ne of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations {Title 40, Pa1t6) _Required Leiter of Not ificatio n _I cenify that the federal regulations regarding asbestos removal are not applicable to t his project. ~ J:L-1 certify that I have read this a ppl.ica ti on and state that the above infonnation is correct. J agree to comply with all City and County ordinances and State Laws relating to building construction. and hereby <mthorize represenlati\1CS of this City and County to enter upon the above mentioned property for inspection~ J Applicant or Agent Signatu re: )' ~ . Dale: • I 2.. L! !._ Z ;;.1~ 7 , Permitce n ame (pri nt): ~ ~-r Lfrr? -..... --,...,,. .,..