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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I herebl'aflinn undo pmalty olpqjury that I dn exempt fiom thc Contrach6' License Law for th€ following rcasn (Se.7011.5 <br />lhsirres md Profssicrn Codc): Any Cily or County which require a pmnit to conslrucl. ah6. irnprove, donolish or rqrair my <br />stnlchue, frior t\] ils i$umcc. also requirBlhe applicant for such penili( to filc a signcd slalsn@t lhat he or she is licemed pmumt. <br />to lhe provisions ofthc (lontractor's Licensed Larv (Chapter 9, Colnmencing with Section 7000 of Division 3 ofthe Business an,l <br />Prof6ionsCodc)orlhatheorshe isexcrnpllhqcliomandthebdisfortheallegedermption. AnyviolationofstrtionT0ll.5byany <br />applicantforapmitsubjectsthc applicanttoacrvilpcnaltyofnotiltorethmlivehundrcddollus($500). <br />I. as orvner oflhe profEl), or my enrploys with $'ags a their *rle compensation. will do the work ed the struduc is not <br />intoded oroffercdforsle(S@.T044,BusinesmCProfessionsCode'l'h€Conlractor'sl-icoscLawdocsnotapplytomownerof <br />thcpRIEty rvhobuildsorimprovsth6@n,ildwhodo6suchuorthtnselforhoselforthroughhisorhsownemploycB. <br />provided that such improvqnenls ee nol intmded oroffsed for $le. I[, horvflq, the building or improvernmt is rcld within one ]w <br />ofcompletion. rhc Owncr l]uildq will havc the burdm ofproving tha he or she did not build or irnprove the prcpoty for the purpow of <br />sl<). <br />l. d\ oMer (,fihe property, dn exclusively conlracling with licensed contrackrs to conslruct lhc prcisl (Str. 7044. Busins <br />ard Proti:sionCode:TheConrraclor'sl.icenscl-awdoanotapplytouownoofpropenywhobuildsorimproveslh6eon. <br />and rvho conlracts for such projccts with a Contmctor(s) licensed pursumt to the Contractor's Licosc Law). <br />I a1r cxempt unds Swtion . B. & P.C. for lhis remon. <br />l)a le <br />WORI(ERS'COMPENSATION <br />DECLARATION <br />I herehy aflim und6 penalty oIgujury one ofthc following dwluatioro: <br />I have md rvill mintain a Certificatc of CoEot to Self-lroure for workm' compmstion. a providcd for by Setion 3700 of the <br />labor ( odc. for the psfommce of the work for which the ptrnit is issued. <br />!/hare and will maintain workm comp€Nation insurance. c required by Sation 3700 of thc Labor Codc. for thc psfommce of <br />the work for which this pmit is issued. My workm comptration insurmce cmiq dd policy numbq re: <br />Carier::/lg P2 lCE Co a P4 L. /-o rZ.s.= L{Esl <br />P,,ti"y N un bo,'. WlL5ll W g Q oo 2-z'Expires: _ <br />I .enify that in the psfonnance ofthc work for vhich this pornit is issued. I shall not qnploy any p€rson in any mmner <br />s 6lo tffome subjsl to the u'orkqs' compsstion larvs of Califomia. dd Elre thal if I should becorne subjst to thc <br />workds'compcnsationprovisionsofSection3T00oftheLahlrCode,lshall.fonhwithcornplywiththoseprovisiore. <br />WARNING: Frailure lo &{ue workss'compmsalion coveragc is unlawful. md shall subject m mploya to oiminal psraltie and <br />civrl fines up to one hundred lhousand dollus ($100.000), in addition to lhe cosl of compemtion. dmages a prolided for thc <br />Scction 1076 oflhc Latrr Code. intercsl and athmc) s fes <br />l)s(r::!4ul-e o <br />I hcreby amrm under pcnalty ofpsjury that I an licen*rl 9 (commqcing wirh Secrhn Toolltuf Division 3 <br />of the Busins md Profssions Code. md my licmse is in full forcc md eflecl <br />l.rcensc <br />.c to Numbs: <br />(billraclor: <br />hcreby amm unds penalty ofperjury thal th6e is a co[slruclion loding agmcl' for thc pofonnance ofthe work for which this perrnit is <br />issued (Se. -1097. Civ. C.). <br />Lcndq s Name: <br />Lender's Address: <br />APPLICAN'T DECLARA'I'ION <br />I hqd:) affm unds pmalty ofperjury one ofthc lollorving dalaations: <br />Dernolition Permits-Asbcstos Notification Fedcral Regulations ( Iitle 40. Pat16) <br />Required Lettq of Nolificalion <br />J ccrtify thal lhe fdlsal regulatiom reguding cbeslos ronoval ue not applicable to this prejet. <br />-/l <br />\4 c*ify rnat I have rcad rhis applicalion ild slale that lhc above infonnation 6 conet. I agre to comply with all City and County <br />ordinancd ed Sralc Lau's relaling to conslnrclioD. md authorizc rcprBmtalivc of this City ad Counly to mt6 upon the <br />above rnmtioned propeny for purms6. <br />Applicanl or Ag6rl <br />l'. rnrillc ilrnrc €f a <br />D,t" 'C)J2o/&t <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />A <br />FINAL )lo 1.t)I Lr- <br />Certificate of Occu <br />Notes, Remarks, Etc. <br />-> <br />rtrr", ' O ,ay' nr/€l a