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BUILD ING-INSPECTOR RECORD SITE-WORK DATE ID/S IG. .. COMMENTS Owner-Builder Declaration I hereby affirm under penally of perjury that I am exc mp l form the Contractors· License Law for the following reason (sec , 7031.5 Business Set Backs :md Profession Code): Any City or County wh ich requires a permit to construe!. alter. improve. demolish or repair any strncturc. prior to its issuance. a lso requires the applicant for such permit to file a signed statement that he or she is licensed pursua nt to the provisions of the Form s/Stee l/Holdowns Contractor's L icensed Law (Chapter 9, Commencing with Section 7000 of D ivision 3 of the Bus iness and Professions Code) or 1hat he or she is exempt therefrom and the basis for the alleged exemption .Any violation of Sect io n 7031.5 by any applicant for a pcnn it subjec1s the Erecti on Pads applicant to a civi l penalty ofnol more than five hundred dollars ($500). UFER Ground _I. as owner of the propeny. or my employees w ith wages as their so le compensation. will do the work and the struclure is not intended or offered for sale ( Sec. 7044, Bus iness and Professions Code: The Con tractor's License Law docs not a pply to an owner of the p ro perty SLAB Floor who builds or improves thereon. and who docs such work himself or herself or through his or her own employees. provided tha1 such improvements are not intended or ofTered for sale. If. however. the building or improvement is sold within one year o f completion. the Subfloor/Vent/lnsul. Owner-Builder will have the burden of prov ing that he or s he not build or im p rove for the purpose of sale). Roof Sheathi ng _I. as owner of the propc11y. am exclusively comracting with licensed contractors to constnict the projecl ( Sec. 7044. Business a nd Profession Code: T he Contractor's License Law docs not a pply to nn owner of property who buikls or improves thereon. and who Shear Wall contracts for s uch projects with a Contrnctor(s) licensed p ursuant 10 the Contractor's L ice nse Lnw.) Framing _, ~m exempt under Section .B. & P.C. for this reason. Date:~ In sulation/E nergy Owner: D rywa ll WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury o ne of the following declarations: Ex t./l nt. Lath _I have and will maintain a Certilicale of Consent to Self-Insure for workers' compensa1ion. as provided fo r by Section 3700 of the Brown Coat Labor Code. for the performance of the work for which the permit is issued, Masonry _I hav e :l.nd will ma intain workers' compensation insu rance. as required by Section 3700 of the L1bor Code. for the performance of the work for which this permit is i~sucd. My workers ' compensation insurance carrier and policy number are: Poo l Fence Carrier: T-Bar Policy Number: Expires: Handicap Req. (This section need not be completed if the permit is for One hundred dollars IS i OOJ or less) Deputy Fina l Report ~ cc11ify that in 1hc performance of the work for which 1his permi1 is issued. I shall not employ any person in a ny manner so as to became subject lo the workers ' compensation laws of C:difo rn ia , and agree that if I should become subject to the workers' Eng ineer Fin a l Report compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions .. Fl ood Zone Certif. Date: t/Z Li. 6//i( Applic ant: ~ I \\'AR NING: Failure to secure workers' compcnsa1ion covcrngc is unlawful, and shall subject an employer to criminal penalties a nd civil lines up to o ne hundred thousand dollars ($100.000).in a ddition to 1hc cos1 of compensation. damages as provided for the Section 3076 of the Labor Code, interest and attorney's fees. FINAL LI CENSED CO NTRACTORS DECL ARA TJON I hereby affirm under penally or perjury that I am licensed under p rov ision of Chapter 9 (c:onuncncing with Section 7000) of Di vision 3 of Certificate of Occupancy 1hc Business and Professions Code. and my license is in full force and effect. Notes, Remarks , Etc. License C lass : C-4 ~ License Number 7cC__/ 7C> q. /,2_/_u/~ I Dille: Contractor: 7 I V.:;> .if. I <;'/~ ' CO NSTRU!;TION LENDI NG AGENCY I hereby affirm under penalty of perjury that there is a construct ion le nd ing agency for !he perfonnance o f the work for which this permit is issued (Sec. 3097. Civ. C.). Lender's Name Le ,,der·s Address: APPLICANT S DECLARATION Dcmo li1ion Pcnni1s-Asbestos Notirication Federal Regulations (Title 40. Part 6) _ Required LctterofNotifica1ion _l cenify 1ha1 the federal regulations regarding asbestos removal are no t applicable to th is project. _ I certify that I have read this application and stnle that the above infonnation is correct. I agree to comply with all City and Counly ordinances And State Laws relating to buildin g construction, and hereby authorize representatives of this Ci1y and County 10 enter upon the above menlioned propeny for inspection purposes. /~?7 -L.Ll~ 11(/ ~ Applicant or agent sig.: Date: Pcrmittee n;une {print): 11 t..J.rv-0 & ,l):;/L))/4.t ._,.. M.\WP511Perm,t-lnspecllon Forms\Bu1ld1ng-lnspect1on Record.doc 03.31.06