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B!Ji !.Dl ~G-INSPECTOR RECORD SITE WORK DATE ID/SIG COl'JI ME Nl"S Owner-BuilderDec laration • • I he re by affi r m under pena lty of perjury that I am exempt form the Contrac1ors' License Law for the following reason (scc.703 1.5 Business Set Backs -a1:d Professio n Code): Any C ity or County which requires a permit to construct. alter. impr ove. de molish or repair any structure. prior to its issua1 .~e. also requires th e applicant for such pcrmi1 to lilc a signed statement that he or she is licensed pursuant to the prov isions of the Form s/Steel/Holdowns Contractor's Licensed Law (Chapter 9. Co1111ne uc in g w ith Seel ion 7000 of Division 3 of the Business and Professions Code) or that h e or she is exe mpt there from and th e basis fo r the alleged e:11:emption .Any vio lation of Section 703 1.5 by any app licant for a perm it subjects the Ere c tion Pads app licant to a civil pena lty of not more than five hundred dollars ($500). 1----------------+-------+-----+-------------«f(iv_ . . . . . . u FER Ground ;,,,:,,,__r_ as owner o f the prope rt y. or my employees with wages as their sole compensation. W Iii do the work and the structure IS DOI Intended or offered for sale ( Sec. 7044, Bus iness and Pro fessions Code: The Contractor·s License Law does not apply to an owner of the prope11y s LAB Floor who builds or improves thereon. and who docs such work himself or herself or through his or her own employees. provided that such imp rovements are no1 intended or offered for sal e. If, however. the bu ildin g or improvement is sold within one year o f comp letion. the Subfloor/Vent/1 nsu I. Owner•Builde r will have th e burd en of proving that he or she not build or improve for the pufl)OSC of sale). Roof Sheathing Shear Wall _I. as owner of the propen y. am exclusively contracting with licensed contractors 10 construct the project ( Sec. 7044. Business and Profession Code: The Contractor's License La w does not apply to an owner of property who builds or imp roves thereo n . and who contracts for such projects with a Contractor(s) licensed pursuant 10 the Contracto r's License Law .). Framing _l am exemp t under Sec tion ________ .B. &j.c. for this eason . .._1--1-t---=-. -,E-------+------+-----f-----------.--~nte• /~·)/-/0 Owner 'f11nA/J nsu a 10n nergy r ~· D II WORKE\l¼MPENSJION DECLARATION ryw a I hereby alTmn und er penalty ofpc1j ury one of the follow in g declarations: E x t.tint. Lath Brow n Coat Masonry Pool Fence _I have and will maintain a Ce11i fica1 e o f Consent to SeJf.J nsure for workers· compensat ion, as provided fo r by Sect ion 3700 of the L1bo r Code. for the performance of the work for whi ch th e pennit is issued. _I have nnd wi ll maintain wor ke rs· compens.'ltion insurance. as required by Section 3700 of t he Labor Code, for 1he performance of the wo rk for which this per111i1 is issued. My workers· compensation in surance carrier and po licy number are: Carrier: __________________________ _ T-Bar Po licy Numbcr:. _____________________ Ex pires: ----------- Handicap Req . (This sectio n need not be completed if the permit is for One hundred dollars {$100} or less) .._D_e_p_u_t_y_F~in_a_l_R~e-p_o_rt--------+-------t------+--------------------1 ~ I certify that in the performance o f the work for wh ich this permit is issued. I shall not employ any person in any manner so as to became subject lo the workers· compensation laws of California, and a gre~;::t,.ifl should become subject to th e workers' Engineer Final Report co mpensation provisio ns of Sect ion 3700 of the La bor Codel:'11. forthw/ ;omply with those provis ions .. 1-=Fl:-o ~od---=-=z :-o -ne----=c :-e :-rt-:--::-if .~-------t-------t-----t-------------'I' l"l!~J , ate: tt-2:I -I~ ¼plicant :~'~"~./~' ,,~_,,,::::::: ______ _ 1----------------+------1---------------------1' 7 u // WARNI NG: Failure lo sec ure workers ' compensation coverage is u~~ful. and sha ll subject an employer to criminal penalties and c iv il FINAL Certificate of Occupancy Notes, Remarks, Etc. fines up to one hundred th ousand dollars ($100.000).in add ition to the cost of compensation. damages as provided for th e Section 3076 of the Labor Code. interest and attorncy·s fees. LICENS ED CONTRACTORS DECLARATION I hereby affirm under penal ty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Divisio n 3 of the Bus iness and Professions Code. and my licen se is in full force and effect. License C lass:. ______________ License Number _______________ _ Date: _____________ Contractor: ____________________ _ CONSTRUCTION L EN DING AGENCY I here by affirm under penalt y o f perjury that there is a construct ion lending agency fo r the perfonnan ce of the work for wh ich thi s permit is issued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lender's Address: _______________________ _ APPLICANTS D ECL AR ATION Demolition Perm i1s -Asbes1os Noti fica tio n Federal Regulat ions (Title 40. Part 6) _ Required Letter of Notifi cation _I ccnify that the federa l regulations regarding asbestos remo,1al are not applicable 10 this project. "';:!'flr, cert ify that I have read this apphcat¥on a: d state tha t the above mforma11on 1s correct I agree to comply with all City and Coumy .._-----------------------------------------------------1 above mentioned prope11y for spect1on p oses 1ffiti'nanccs and Stat e Law;52rel mg to bmld1 g construct1on. and hereby authonze representa tives of th1S City and Coun ty to enter upo n the .._-----------------------------------------------------1~\ppli cant or agents1g ,ii l1 1 , Dat e / j ·)/-I {p 1------------------------------------------------------,,.<1'1n~.•ermittee name (print): V f -r-tr-eStt Le M.\WP51\Perm1 t-lnspecti on Forms\Bu1lding-lnspect1on Record.doc 03.31.06