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SITE-WORK DATE ID/SIG,.. Set Backs Forms/Steel/Holdowns Erection Pads Vt\....,/ UFER Ground SLAB Floor Subfloor/VenUlnsulation I Roof Sheathing Shear Wall Framinq I nsulation/Enerqy l Y, Drywall E xt.II nt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req. BUILDING-INSPECTOR RECORD COMMENTS OWNER BUILDER DE L CARATION I hereby affirm under penall y o f perj ury 1hm I am exempt from the Contractors· License La w for the following reason (Scc.7031.5 Business and Profession Code): Any City or County which requires a penni t to constn.ict. alt er. im prO\'C. demolish or. repair any structure. prio r to its issuance. also requires the appl icant for such pennit to fil e a s igned statement that he or she is licensed pursuunt to the provisions o f the Contractor's Li censed Law (Chapter 9. Commencing with Section 7000 of Division 3 of the Business and Professions Code) or that heor she is exempt therefro m and the basis for the alleged exempt ion. Any violation of Section 7031.5 by any applicant for a pcm1it subjects the applicant to a civ il penalty o r not more Limn five hundred do ll ars ($500). _I. as owner of the property. or my employees wit h wages as their sole compensat ion, will do the work ru,d the stnicture is not intended or offered for sale (Sec. 7044, Busin ess and Professions Code: The Contra ctor·s License Law does not apply to an owner of the property who buil ds or improves thereon. and who does such ,vork himself or herself or thro ugh hi s or her own employees. provided that such improvements are not intended or offered fo r sale. If. however, the bu ilding or improvement is so ld within one year of comp letion. the Owner Build er will have the burden o f proving that he or she did not build or improve the propeity for the pmposc of ti/). as owner of t he property. run exclusively contracting with li censed contractors to construct the project (Sec. 7044. Business and Profession Code: T he Contractor's Li cense Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projects with a Contractor(s) li censed pursuant to the Contractor's License Law). _1 am exe_n!t "Ider !j<etion ~ for this reason. Dale ,fq/;//0 Owner: ~~~ I l WORKERS' CO~IPllNSATION DEC LARATION I hereby affirm under penalt y of perjury one o r the following declarations: _I have and will maintain a Certificate of Consent to Self-Insu re for wol'kcrs · compcnsalion, as provided for by Section 3700 of1he Labor Code. for the perfonnance of th e wo rk fo r which the pcnnit is issued. _I have and wi ll maintain workers · compensation insura nce. as required by Section 3700 of th e Labor Code. for the perfon nance of t he work for which this pennit is issued. My wo rkers ' compensation in surance carrier and policy number are: Deputy Final Report ~Numbcr; _____________ Expires: Enqineer Final Report t--~'---------L--------l-------+------1------------------~ _ ertify that in the performance of the work for which th is permit is issued. I shall nol employ any p<..-rson in any manner Flood Zone Cert.if. so as to become subjecl 10 the workers' compensat ion laws ofCalifom ia, and agree that if I should become subjec t to the workers· compensation prov isions of Sect io n 3700 of the Lalxlr Code. I shall. forthwith comply with those provisions. WAltNLNG: Fai lure to secure workers' compens at ion coverage is unlaw ful. and sha ll subj ect an empl oyer to a iminal penalties and : FINAL civil fi nes up to one hundred tho usand do ll ars ($100.000}. in addition to 1he cost or compcnsa1,·~on. da iages as provided for the Sectio n 3j 76 of 1 c La bor f ode. interest and attorney's fees. / /4, ~.4 ././ ~ Dale: La.,//;, / {?, Appli ca nl:,.,,.:~=~.!,.,<,t"~ /4.c..,<:~.!e:,~:,C.,,..:/,:_:vt-=---.,..'-----~~-ll'---11--- Certificate of Occupancy V V Notes, Remarks, Etc. / ( LICENSED CONTRACTOR LU DECLARATION I hereby affirm under penalty o f perj ury that I am licensed under provis ion of Chapter 9 (commenc ing with Sectteln 7000) o f Div ision 3 of the Business and Professions Code. and m y license is in full force and cITcct. Lice nse Class: ______________ Licensc Number: _______________ _ Dntc: ____________ Contrnclor: _____________________ _ CONSTRU CTION LENDING AGENCY 1 hereby affirm under penalt y of perj ury that there is a co nstructio n lending agency for the perfonnance of the work for which this permit is issued (Sec. 3097 . Civ. C.). Lender's Name: _________________________ _ Lender's Address: _________________________ _ ;\PPLICANT DECLARATION I hereby affinn under pena lty of perj ury one o f the fo llowing declarations: Demo lit ion Permits·Asbestos Notification Federal Regul at ions (Tit le 40. Part 6 ) _Requi red Letter ofNotifi catKm 1----------------------------------------------------~~I certify that t he federal regulations regarding asbestos removal are not appl ic abl e to this project. ~ \/:Jli certify that I have read this application and state that the above info rmation is correct. I agree to comply with all Ci1y and County 1-----------------------------------------------------'I orclinances and State Laws relat ing to buil ding construct io n. and hereby a ~1horize epresentat ives of this City and County to enter upon the above mentioned propcny for ins pection P"?J'· ,. .,-:;:?" / 2 // J, Applicant o r Agent Signature: -,t... ~ _d,~~~? ~~,.,.._-Dale: • Lft:::::>d ~ /1 /-4,__,,n,.,."7 L=--Y~_..r----I { Pcrmite:e name: (print):_°?_"'~--l~/6, ~'~-~~r~JLZJ.t-~t-8. L:A..~..__ _ _f,~~'.A-c;~~::'./~~~---....:_ __ _!'.__ {/ u